CoHege  of  ^Ijpgiciang  anb  burgeons 
Hibrarp 


TROPICAL  SURGERY 

AND 

DISEASES  OF  THE  FAR  EAST 


TROPICAL  SURGERY 

AND 

DISEASES  OF  THE  FAR  EAST 

INCLUDING  ANSWERS  TO  A  QUESTIONNAIRE 


BY 

JOHN  R.  McDILL,  M.D.,  F.A.C.S. 

Major,  Medical  Eeserve  Corps,  United  States  Army. 

Lecturer  on  Surgery,  Rush  Medical  College,  University   of  Chicago;   Former  Professor 
and  Head  of  Department  of  Surgery,  College  of.  Medicine  and  Surgery,  University 
of    the    Philippines;    Chief    Surgeon,    Philippine    General    Hospital,    St.    Paul's 
Hospital,    and    Cosmopolitan    Hospital,    Manila;    Former    Major    of    Volun- 
teers   and    Chief    Operating    Surgeon    in    the    Field,     Seventh    Army 
Corps    in    Cuba,    and    to    the    First    Reserve    Hospital    in    Manila; 
Fellow   Society  of  Tropical  Medicine  and  Hygiene   (London), 
Far    Fastern    Association    of    Tropical    Medicine,    Ameri- 
can  Medical   Association,   etc. 


Approved  for  Publication  by  the  Surgeon  General 
of  the  United  States  Armv 


ST.  LOUIS 

C.  V.  MOSBY  COMPANY 
1918 


IV)  1^ 


Copyright,   1918,  By   C.   \'.  Mosey   Compaxy 


Press  of 

C.  V.  Mosby  Company 

St.  Louis 


Dedicated  to  My  Dear  Friend,  Doctor  Ariston 
Bautista  y  Lim  of  Manila,  Professor  of  Clinical 
Medicine  in  the  College  of  Medicine  and  Surgery, 
University  of  the  Philippines,  in  Appreciation  of 
His  True  Friendship  and  of  His  Unselfish  Devotion 
TO  the  Advancement  of  His  People. 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/tropicalsurgerydOOmcdi 


FOREWORD 


The  winning  of  the  world  war  demands  the  assembling 
of  all  knowledge  which  may  be  of  possible  use.  Surgical 
as  well  as  medical  diseases  of  the  Tropics  are  already 
encountered  in  all  armies,  not  only  during  their  tropical 
service,  but  in  that  in  Europe  and  America  as  well.  The 
author  having  noted  this  fact  during  overseas  sexvice 
in  1916-1917  has  put  together  material  which  he  has  been 
collecting  for  years  and  has  added  abstracts  of  recent 
literature  in  the  hoi:>e  that  such  a  compilation  may  be 
of  some  value  during  and  after  the  war. 

Opportunities  for  observation  were  found  in  a  prac- 
tically^ continuous  life  of  fourteen  years  in  the  Tropics ; 
in  our  South,  Cuba,  the  Philippines,  and  in  frequent 
visits  to  China  and  Japan.  Four  years  of  this  time  were 
served  as  a  volunteer  surgeon  in  the  United  States  Army, 
as  chief  operating  surgeon  to  an  army  corps  in  the  field 
in  Cuba,  in  Luzon  with  troops  in  the  field,  and  in  base 
hospitals  in  Manila  as  operating  surgeon.  Ten  A^ears 
were  spent  in  jDrivate  and  public  practice  in  Manila  dur- 
ing which  many  medical  institutions  were  organized. 
The  clinical  data  in  Part  I  are  mostl}^  from  the  last  five 
thousand  carefully  recorded  surgical  cases  among  Fil- 
ipinos. The  material  of  Part  II  was  derived  from  travel 
and  personal  contact  with  many  of  the  medical  men  in 
China,  Japan,  Indo  China,  and  the  Straits  Settlements, 
as  well  as  from  answers  to  a  questionnaire  sent  to  over 
two  thousand  medical  men  in  the  Tropics.  The  ground 
covered  in  Part  II  includes  -the  Philippines,  JaiDan,  China, 
Indo  China,  Ceylon,  Straits  Settlements,  Guam,  Samoa, 
Burma,  India,  and  parts  of  Africa  in  all  of  which  countries 

7 


8  FOREWORD 

the  allied  ti'oops  arc  already  in  the  field.  The  medical  men 
who  contributed  data  are  prominent  in  their  fields,  many 
have  been  living  in  Far  Eastern  countries  the  best  part 
of  their  lives  and  are  still  there.  The  best  reports 
were  from  United  States  Army  Surgeons  Chamberlain, 
Phalen,  Vedder,  Nichols,  and  Page  and  from  surgeons 
of  the  United  States  Navy,  especially  Surgeons  Cottle 
and  Odell.  The  reports  and  published  Avorks  of  the 
surgeons  in  the  i^nglo-Indian  medical  service,  which 
were  kindly  furnished  by  the  Honorable  Surgeon- 
General  C.  P.  Lukis,  of  Calcutta,  were  splendid  and  con- 
tained important  original  work  by  such  men  as  Sir 
Havelock  Charles,  Major  Leonard  Rogers,  Sir  Ronald 
Ross,  and  Austin  Smith  of  Agra.  Of  great  general  in- 
terest are  the  descriptions  by  the  medical  missionaries, 
especially  in  China,  among  whom  were  Snell  of  Soochow, 
Plummer  of  Wenchau,  and  Margaret  E.  Philipps  of 
Ping  Yin;  Ralph  G.  Mills  of  Seoul,  Korea,  and  sixteen 
colleagues,  practicing  in  Korea  for  an  average  of  ten 
years  each,  made  the  questionnaire  the  subject  of 
a  symposium.  Landsborough  of  Formosa,  Turner  of 
South  Africa,  Hollenbeck  of  AVest  Africa,  Castellani,  de 
Silva  and  Faul  of  Ceylon,  Castor  of  Burma,  and  many 
others  have  made  valuable  contributions  both  to  literature 
and  in  personal  communications  concerning  tropica! medi- 
cine and  surgery. 

This  information  and  my  own  experience  bear  out  the 
truth  that  the  broad  principles  of  epidemiolog}^,  prophy- 
laxis, pathology,  and  therapeutics  are  equally  applicable 
everywhere,  and  that  there  is  no  foundation  for  the  idea 
that  diseases  met  with  in  other  countries  can  be  classed 
as  special  in  type  or  differing,  except  in  pathologic  range, 
from  the  diseases  of  our  own  and  European  countries, 
although  the  anomalies  and  curiosities  of  a  foreign  med- 
ical experience  have  their  interesting  features.  When 
the  important  diseases  knoA^m  as  "tropical,"  which  are 


FOREWORD  ■  9 

now  being  discovered  everywhere,  appear,  the  question 
of  their  origin  is  invariably  answered  by  pointing  to  the 
constantly  improving  means  of  comnmnication  around  the 
world  and  to  the  fact  that  diseases  always  follow  the 
paths  of  commerce  and  the  march  of  armies. 

J.  R.  M. 

June,  1918. 


CONTENTS 


PART  I 


The  Conditions  Supposed  to  Modify  Surgical  Procedure  in  the 
Tropics,  Surgical  Diseases  Earely  Seen  Elsewhere,  Also  Those  Seen 
Mostly  in  Equatorial  Lands  but  Transportable  to  Other  Countries 
and  Likely  to  Come  Within  the  Experience  of  any  Medical  Man. 

CHAPTER  I  ^ 

Introduction 
Litioduction,  17. 

CHAPTER  II 

Surgery  -and  Surgical  Operations 
Surgery  and  Surgical  Operations,  22. 

CHAPTER  III 

Diseases  of  the  Head,  Neck  and  Thorax 
The  Head  and  Neck,  25 ;  Congenital  Defects  and  Anomalies,  25 ;  Injuries 
and  Results  of  Injuries  and  Disease,  25;  Cysts,  Fistulas  and  Torticollis  of 
Neck,  Rare,  25 ;  Ludwig  's  Angina,  25 ;  Tuberculosis  and  Hodgkin  's  Dis- 
ease, etc.,  Neck,  26;  Cancer,  Cysts,  and  Osteomyelitis,  27;  The  Thorax,  29; 
Bronchomycosis  and  Bronchomoniliasis,  30. 

CHAPTER  IV 

The  Abdomen 

The  Abdomen,  33;  Hernia,  33;  The  Spleen,  34;  Splenic  Anemia  and  the 
Kala-azar,  34;  The  Colon,  37;  Entamebic  Dysentery,  37;  History,  Walker 
and  Sellards,  37;  Diagnosis,  Treatment,  and  Prophylaxis,  39;  Balantidial 
Dysentery,  63;  Bacillary  Dysentery,  66;  General  Intestinal  Parasitism,  67; 
Influence  on  Surgical  Prognosis,  67;  Relation  to  Typhoid  Hemorrhages, 
68 ;   The , Liver,  69  ;  Entamebic  Abscess,  69. 

CHAPTER  V 

Gynecology  and  Obstetrics 
Gynecology  and   Obstetrics,   86;    Pelvic  Inflammatory  Diseases,   86;    Ob- 
stetric Customs,  86 ;   Tumors,  89. 

11 


ILLUSTEATIONS 

FIG.  PAGE 

1.  Encephaloeystocele '  .     . 26 

2.  Enormous  goiter  with  colloid  and  fatty  degeneration 27 

3.  Cancer  of  the  mouth  and  extension  to  the  neck  in  a  iDetel  nut  cliewer     28 

4.  Cancer  of  the  cheek  and  face  from  primary  cancer  of  buccal  mucosa 

in  a  betel  nut  che\yer 29 

5.  Multiple  areas  of  necrosis  in  acute  entamebiasis 38 

6.  Multii)le    ulcerations    severe    chronic    entamebiasis 39 

7.  Typical   examples   of   Ameba   and   Entameba 47 

8.  Colon  of   a  man  dead  from  Balantidium   eoli  infection     ....     63 

9.  Section  of  large  intestine   of  monkey,  sho\ving  three  Bialantidium 

coli  suis  in  the  deeper  part  of  the  mucosa 64 

10.  Section  of   a   mesenteric  lymph  gland   of  monkey,   showing   several 

Balantidium  coli  hominis  in  the  edge  of  the  glandular  tissue     65 

11.  Section  of  large  intestine  of  a  man  dead  fr.om  Balantidial  dysen- 

tery      66 

12.  Liver.     Upper  surface  showing  minute  multiple  foci  of  secondary 

infection   from   entamebiasis   of   the   colon 70 

13.  Liver.     Cut  surface  of  same  spiecimen  as  Fig.  12     .     .    \     .     .     .     70 

14.  Liver.     Section  of  right  lobe  with  large  multiple  abscesses     ...     71 

15.  Liver.     Solitary  superficial  entamebie  abscess  on  outer  surface  of 

right  lobe 72 

16.  Curvilinear   incision   to    expose    9th   and    10th   ribs 72 

17.  Resection  of  four  inches  of  10th  rib;  resulting  gutter  to  be  closed 

immediately    by    catgut    suture 73 

18.  Cavity  or   gutter   left   liy  rib   resection,   partly   sutured     ....     73 

19.  While  incision  into  the  peritoneal  cavity  is  being  made  the  mobilized 

chest  wall  is  held  firmly  against  the  diaphragm  by  two  fingers 

of  an  assistant ~'^ 

20.  Edges   of   chest   wall   and   diaphiagm,   which   are   to   be   united   by 

suture,  held  apart '"^ 

21.  Suture  of   chest  wall  and   diaphragm  completed,   showing  exposure 

of    liver "6 

22.  Mikulicz  pack  to  procure  adhesions  after  failure  to  find  an  aljscess     77 

14 


ILLI'STTIATFOXS  15 

FIG.                                                                                                                                           PAGE 
2?,.  Drain  in  place,  gauze  ring  around  tubo'  to  prevent  soiling  of  peri- 
toneum and  to  form  adhesions 78 

24.  Diagramniiitic  sketch  showing  layers  incised  and  digital  method  of 

temporarily  preventing  pneumothorax  till  diaidiragm  and  chest 

wall  are  sutured • 79 

25.  Combination  drain  and  hemostat  for  liver  abscess 81 

26.  Combination  drain  and  hemostat  intiated  in  a  liver  abscess  specimen  82 

27.  Liver.     Roundworm  invasion  through  large  common  duct,  showing 

small  abscesses • 83 

28.  Liver.     Roundworm  invasion  through  large  common  duct,  showing 

smair  abscesses • 84 

29.  Ovarian  cysts 87 

30.  A  six  months'  abdominal  lithopedion,  carried  seven  years     ...  88 

31.  Filaria  nocturna 96 

32.  Head  end  of  Filaria  nocturna 96 

33.  Filaria    nocturna 97 

34.  Beginning  elephantiasis  in   an  American  in  Manila 100 

35.  Chronic  elephantiasis  nostras  streptogenes  of  scrotum  and  leg     .  101 

36.  Neurofibromatosis   resembling   elephantiasis 102 

37.  Silk   covered   with   memlirane   at   angle   with   parietal   peritoneum 

shows  ectropion 109 

38.  Instruments   for  inserting   silk   in   peritoneal   cavity 109 

39.  Silk  for  insertion  in  peritoneal  cavity 109 

40.  Gangosa  cases  in  Guam  with  nasopharyngeal  involvement     .     .     .  118 

41.  Group   of   gangosa   cases   in    Guam 119 

42.  Group  of  gangosa  cases  showing  marked  disfigurement  following 

nasopharyngeal  lesions 120 

43.  Gangosa  lesions 121 

44.  Extensive  gangosa  mutilation  in  a   Filipina 122 

45.  Gangosa 1-3 

46.  Yaws   in   Samoa 126 

47.  Yaws 127 

48.  Yaws 1-8 

49.  Gristly  healing  of  tiopical  phagedenic   ulceration 131 

50.  Syphilitic  ulcerations  in  Filipino 132 

51.  "Tropical   ulceration."      Bone    exposed 133 

52.  Early  nodular  leprosy 134 

53.  Advanced    nodular   leprosy 135 


ILLUSTKATIONS 

FIG.  PAGE 

1.  Encephaloeystoeele 26 

2.  Enormous  goiter  with  colloid  ami  fatty  degeneration 27 

3.  Cancer  of  the  mouth  and  extension  to  the  neck  in  a  betel  nut  chewer     28 

4.  Cancer  of  the  cheek  and  face  from  primary  cancer  of  buccal  mucosa 

in  a  betel  nut  chewer 29 

5.  Multiple  areas  of  necrosis  in  acute  entamebiasis 38 

6.  Multiple    ulcerations    severe    chronic    entamebiasis 39 

7.  Typical   examples   of   Ameba   and   Entameba 47 

8.  Colon   of   a  man   dead   from  Balantidium   eoli   infection     ....     63 

9.  Section  of  large  intestine   of  monkey,  showing  three  Balantidium 

coli  suis  in  the  deeper  part  of  the  mucosa 64 

10.  Section  of   a   mesenteric  lymph  gland   of  monkey,   showing   several 

Balantidium  coli  homiuis  in  the  edge  of  the  glandular  tissue     65 

11.  Section  of  large  intestine  of  a  man  dead  fr.om  Balantidial  dysen- 

tery      66 

12.  Liver.     Upper  surface  showing  minute  multiple  foci  of  secondary 

infection   from   entamebiasis   of   the   colon 70 

13.  Liver.     Cut  surface  of  same  specimen  as  Fig.  12     .     .    \     .     .     .     70 

14.  Liver.     Section  of  right  lobe  with  large  multiple  abscesses     ...     71 

15.  Liver.     Solitary  superficial  entamebie  abscess  on  outer  surface  of 

right  lolie 72 

16.  Curvilinear   incision   to    expose    9th   and    10th   ribs 72 

17.  Eesection  of  four  inches  of  10th  rib;  resulting  gutter  to  be  closed 

immediately    by    catgut    suture 73 

18.  Cavity  or   gutter   left   by  rib   resection,   partly   sutured     ....     73 

19.  While  incision  into  the  peritoneal  cavity  is  being  made  the  mobilized 

chest  wall  is  held  firmly  against  the  diaphragm  In-  two  fingers 

of  an  assistant "^ 

20.  Edges   of   chest   wall   and   diaphragm,   which   are   to   be   united   by 

suture,  held  apart '^5 

21.  Suture  of   chest  wall  and   diaphragm  completed,   showing  exposure 

of    liver "6 

22.  Mikulicz  pack  to  procure  adhesions  after  failure  to  find  an  aliscess     77 

14 


ILLT'STRATIDXS  15 

FIG.  PAGE 

23.  Drain  in  place,  gauze  ring  aiouml  tulio  to  prevent  soiling-  of  peri- 

toneum and  to  form  aflliesions 78 

24.  Diagrammatic  sketch  showing  layers  incised  ami  digital  method  of 

temporarily  preventing  pneumothorax  till  diaphragm  and  chest 

wall  are  sutured • 79 

25.  Combination  drain  and  hemostat  for  liver  abscess SI 

26.  Combination  drain  and  hemostat  inilated  in  a  liver  abscess  specimen  82 

27.  Liver.     Roundworm  invasion  through  large  common  duct,  showing- 

small  abscesses ■ 83 

28.  Liver.     Roundworm  invasion  through  large  common  duct,  showing 

smair  abscesses • 84 

29.  Ovarian  cysts • 87 

30.  A  six  months'  abdominal  lithopedion,  carried  seven  years     ...  88 

31.  Filaria  nocturna 96 

32.  Head  end  of  Filaria  nocturna 96 

33.  Filaria    nocturna 97 

34.  Beginning  elephantiasis  in  an  American  in  Manila 100 

35.  Chronic  elephantiasis  nostras  streptogeues  of  scrotum   and  leg     .  101 

36.  Neurofibromatosis   resembling   elephantiasis 102 

37.  Silk   covered  with   membrane   at   angle   with   parietal   peritoneum 

shows  ectropion 109 

38.  Instruments   for   inserting   silk   in   peritoneal   cavity 109 

39.  Silk  for  insertion  in  peritoneal  cavity 109 

40.  Gangosa  cases  in  Guam  with  nasopharyngeal  involvement     .     .     .  118 

41.  Group   of   gangosa    cases    in    Guam 119 

42.  Group  of  gangosa  cases  showing  marked   disfigurement  following 

nasopharyngeal  lesions 120 

43.  Gangosa  lesions 121 

44.  Extensive  gangosa  mutilation  in  a   Filipina 122 

45.  Gangosa 1-3 

46.  Yaws   in   Samoa 126 

47.  Yaws 127 

48.  Yaws 1-8 

49.  Gristly  healing  of  tiopical   phagedenic   ulceration 131 

50.  Syphilitic  ulcerations  in  Filipino 132 

51.  "Tropical   ulceration."      Bone    exposed 133 

52.  Early  nodular  leprosy 134 

53.  Advanced    nodular   lepros}- 135 


16  ILLUSTRATIOXS 

FIG.  PAGE 

54.  Pure  nerve  leprosy 1.36 

55.  Xerre    leprosy.      Infiltration    of    hand 1.37 

56.  Xerve    leprosy.      Plantar    jiedis    ulcer 138 

57.  Macular  leprosy 139 

58.  Madura  foot 149 

59.  Ainhum 151 

GO.  Female    pregnant    chigger 152 

61.  Male  chigger 152 

62.  Goundou  and   leoutiasis 153 

63.  Pyogenic  infection  of  hand 156 

64.  Pyogenic  infection  picture  taken  at  a  time  when  gangrene  of  the 

forefinger  had  set  in 157 

65.  SjTnmetrical   fibromata 180 

66.  S.^Tnmetrical  fibromata  on  forearms  and  ankles 181 

67.  "Fuente, "  showing  ball  of  wax  in  ulcer  for  permanent  counter- 

irritation  against   all   diseases 182 

68.  The  Bevan  incision  for  splenectomy,  method  of  using  gauze  pack 

for  temporary  hemostasis 291 

69.  Closure  of  sx:)lenic  si^ace  by  snaking  catgut  suture     ......  295 


TROPICAL  SURGERY  AND  DISEASES 
OF  THE  FAR  EAST 


PART  I 

THE  CONDITIONS  SUPPOSED  TO  MODIFY  SURGICAL 
PROCEDURE  IN  THE  TROPICS,  SURGICAL  DISEASES 
RARELY  SEEN  ELSEWHERE,  AND  THOSE  SEEN  MOST- 
LY IN  EQUATORIAL  LANDS  BUT  TRANSPORTABLE  TO 
OTHER  COUNTRIES  AND  LIKELY  TO  COME  WITHIN 
THE  EXPERIENCE  OF  ANY  MEDICAL  MAN. 


CHAPTER  I 
INTRODUCTION 

The  sixty  degrees  of  latitude  of  tlie  earth's  surface 
in  the  torrid  and  subtorrid  zones,  embracing  forty-seven 
countries  with  a  billion  people,  are  the  future  treasure 
houses  of  the  world,  and  it  is  the  Western  medical  man 
who  will  make  possilile  the  evolution  of  these  undeveloped 
l)ut  no  longer  far-off  or  mysterious  lands  by  converting 
their  waste  places  into  suitable  habitations,  not  only  for 
tlieir  own  populations,  but  also  for  the  exotic  human 
transplant  wlio  will  1)e  necessary  for  the  initiation  oP  the 
change. 

The  white  man's  dread  of  tropical  disease  and  trop- 
ical sunlight  has  been  proved  unfounded.  After  a  few 
slight  physiologic  irregularities,  which  soon  adjust  them- 
selves, he  has  little  to  fear  from  so-called  tropical  dis- 
eases, which  are  all  infections,  are  usually  avoidable,  and 

17 


18  TROPrCAI.    .SURGERY    AXD    DISEASES 

Avliose  treatment  is  now  so  well  nnderstood  that  the 
death  rate  of  the  white  races  in  well-ordered  trox)ical 
colonies  is  as  low  as  in  onr  hest  regnlated  cities  in 
Europe  or  America. 

Knowledge  of  the  diseases  of  other  parts  of  the  world 
is  as  important  to  medical  men,  especially  to  medical 
officers  of  onr  armies,  as  is  information  concerning 
their  connnercial  needs  and  resources  to  the  business 
world  liecanse  all  are  being  brought  ever  nearer  to- 
gether by  the  world  war  and  by  constantly  improving 
methods  of  communication.  It  was  not  so  very  long  ago 
that  the  development  of  a  few  cases  of  a  dreaded  epi- 
demic disease,  brought  from  some  far  off  pestilential 
spot,  struck  terror  from  the  coast  to  the  interior  and 
paralyzed  our  commerce  to  the  extent  of  millions  of 
dollars.  The  former  panics,  the  blind  and  costly  errors 
hastily  made  for  protection,  are  unheard  of  now  because 
scientific  medicine  has  discovered  the  methods  of  the 
transmission  of  disease  and  promptly  and  quietly  safe- 
guards human  life  and  commercial  interests  with  a  min- 
imum of  public  alarm. 

The  world's  debt  to  experimental  medicine  can  not  be 
calculated.  Vaughan  has  pointed  out  that  the  glory  of 
ancient  civilizations  departed  on  account  of  disease  and 
that  the  map  of  the  earth  has  been  changed  far  oftener 
by  microbes  than  by  wars.  In  China  in  the  fourteenth 
century  thirteen  million  died  from  the  "Black  Death" 
and  in  Europe  from  1347  to  1350  twenty-five  million  per- 
ished from  the  same  cause;  in  the  eighteenth  century, 
sixty  million  people  died  from  smallpox  in  Europe  alone. 
For  centuries  men  have  sought  the  causes  of  yellow  fever, 
plague,  malaria,  and  other  diseases,  and  some  of  the 
guesses  were  near  the  mark.  The  Egyptians  made  the  cat 
a  sacred  animal  because  where  cats  flourished  there  was 
no  plague,  but  the  relations  between  the  cat  and  the  rat 
did  not  suggest  anvthing.     Sir  Henrv  Blake  saw  a  med- 


IXTltODrCTlOX  19 

ieal  l)()()k  in  C'cyloii,  t'oiirtccii  liuiidi-ed  years  old,  wliifli 
charged  the  mosquito  with  eai'i'viiig  inaUu-ia.  But  it  was 
not  until  twenty  years  ago  that  the  principle  of  insect- 
borne  diseases  was  fully  established.  ]\Ianson,  in  1883, 
proved  the  mosquito  to  be  the  intermediate  host  of  fila- 
ria,  while  Sir  Ronald  Ross  demonstrated  the  real  truth 
of  the  principle  of  insect-borne  diseases  only  seventeen 
years  ago ;  he  little  dreamed  that  it  was  to  be  but  the  be- 
ginning of  a  long  series  of  related  discoveries  which 
would  entirely  end  humanity's  helplessness  in  the  face  of 
epidemic  disease.  To  Koch  we  owe  our  knowledge  of 
cholera,  plague,  and  African  tic  fever.  Reed,  Carroll,  and 
Lazear  of  the  Medical  Corps  of  the  United  States  Army, 
proved, — Lazear  at  the  cost  of  his  life  and  Carroll  al- 
most,— that  the  Stegomyia  plays  the  same  role  with  "Yel- 
low Jack"  that  the  Anopheles  does  ^\T.th  malaria.  In  a 
one  thousand  bed  military  held  hospital  full  of  typhoid, 
at  Jacksomille,  in  1898,  Reed,  Vaughan  and  Shakespeare, 
as  a  conmiission,  demonstrated  to  us  that  millions  of 
germs  Avere  on  the  feet  of  our  millions  of  flies  and  that 
they  carried  the  infection  from  the  latrines  direct  to  the 
mess  tables.  Amebic  dysentery  should  soon  be  under 
control  owing  to  the  epochal  work  by  AYalker  (1914)  and 
to  the  discovery  of  emetin  by  Rogers  (1912).  Thus  the 
new  creed  of  universal  health  bans  the  moscpiito  breeder 
of  malaria,  filariasis,  and  dengue,  the  flea  of  bubonic 
plague,  the  lice  of  typhus,  the  tsetse  fly  of  sleeping- 
sickness,  and  the  tic  of  spotted  fever;  and  man  is  not  the 
only  beneficiary,  but  his  domestic  animals  as  Avell. 

The  prevalence  of  the  epidemic  diseases  in  the  torrid 
zone  has  made  it  the  great  field  for  research  and  relief 
workers,  and  today  millions  of  souls  in  and  near  the 
equatorial  belt  are  freed,  not  only  from  the  devastation 
of  epidemic  diseases,  but  also  from  that  of  the  hookworm 
Avhich  AVickliffe  Rose  has  shown  in  his  i-eport  of  1911  has 
deprived  them  of  two-thirds  of  their  efficiency ;  Africa  is 


20  TROPICAL    SURGERY    AXD    DISEASES 

awakening-  from  the  sleeping  sickness  which  made  it 
" Tlie  Dark  Continent,"  and  preventive  medicine  is  every- 
where writing  new  geography  of  habitable  territory  and 
commercial  opportnnity.  To  the  tropics,  when  cleaned 
up,  we  can  look  for  the  world's  future  supjDly  of  food,  as 
our  grazing  areas  are  being  rapidly  encroached  upon  for 
farming  purposes  and  the  corn  and  wheat  areas  are 
dwindling  in  proportion  to  the  increase  of  population. 
And  the  beauty  of  it  all  is  that  the  economic  value  to  the 
Avorld  of  scientific  medical  research  is  represented  by  only 
an  insignificant  fraction  of  its  cost,  while  it  makes  pos- 
sible the  development  of  any  section  of  the  earth,  pro- 
vided the  price  of  its  sanitation  is  furnished.  The  work 
of  Surgeon-General  Gorgas,  which  will  eventually  be 
acknowledged  as  the  greatest  single  achievement  which 
made  the  success  of  the  Panama  Canal  possible,  Avas  clone 
for  five  ]3er  cent  of  the  total  expense.  Any  nation  or  any 
community  at  home  or  abroad  can  now  fix  its  own  death 
rate  b}^  the  amount  of  money  it  is  willing  to  spend.  It 
has  become  almost  axiomatic  that  preventable  ill  health 
is  a  social  crime  and  that  the  man  or  the  community  that 
suffers  in  consequence  has  only  self  to  lilame. 

In  writing  on  the  surgery  of  these  lands  in  its  diag- 
nostic and  therapeutic  aspects  it  is  not  possible  or  desir- 
able to  sharply  separate  the  surgical  from  the  medical 
and  from  the  other  general  conditions;  the  subject  needs 
to  be  treated  as  a  whole  or  a  wrong  conception  will 
be  acquired  of  the  snrgical  problems  encountered.  Our 
greatest  lesson  from  the  combination  of  modern  science 
and  business  in  the  treatment  of  disease  an^^^vhere,  is 
that  there  is  absolutely  no  competition  between  the  med- 
ical, the  surgical  and  the  other  branches  of  our  art,  so 
that  in  remedial  measures  surgery  is  merely  the  mechan- 
ics of  therapy. 

The  general  principles  of  pathology,  therapeutics,  and 
operative  technic,  common  to  all  fields  of  surgery,  apply 


INTHODUCTIOiSr  21 

in  all  i^arts  of  the  Avorkl.  Strictly  tropical  diseases  are 
few  and  unini})ortant  and  can  be  described  in  a  few 
words.  ' '  Tropical  disease  "  is  a  term  of  convenience,  but 
is  liardly  more  accurate  than  would  be  the  term  ''arctic 
disease;"  though  frost  bite  may  be  as  rare  in  the  tropics 
as  heat  prostration  is  in  the  arctics,  neither  affection 
could  be  classified  as  a  strictly  climatic  condition.  Cer- 
tain surgical,  as  well  as  medical,  diseases,  whose  causative 
agent  is  ubiquitous,  flourish  best  in  the  warm  countries, 
but  their  frequency  and  their  control  depend  uiDon  per- 
sonal hygienic  and  general  sanitary  measures  whose  prin- 
ciples are  also  as  universally  applicable  as  are  those  of 
surgery.  Good  surgery,  like  gold,  is  wherever  one  finds 
it  and  is  not  modified  in  any  way  by  climate.  So-called 
tropical  surgery  and  tropical  medicine  are  only  medicine 
and  surgery  as  they  occur  in  the  tropics.  All  diseases  are 
cosmopolitan;  their  relative  incidence  and  the  general 
conditions  under  which  they  occur  make  the  only  differ- 
ence. 


CHAPTER  II 
SURGERY  AND  SURGICAL  OPERATIONS 

Correct  clinical  surgery  does  not  vary  anywhere  in 
the  world;  the  organization  of  a  proper  clinic  in  the 
tropics  requires  the  assembling  of  exactly  the  same  units 
and  material  as  elsewhere ;  untoward  results  of  any  oper- 
ation can  always  be  traced  to  a  defect  in  technic.  The 
most  serious  condition  facing  a  clinic  in  the  Far  East  is 
the  distance  from  bases  of  supply  and  the  absence  of  a 
body  of  trained  doctors  and  nurses  from  which  to  select 
and  develop  an  operating  personnel,  because  when  an  op- 
erating group  is  brought  together,  the  vacations,  sickness 
and  vacancies,  which  are  always  occurring,  are  often 
hard  to  fill  without  sending  to  the  homeland  or  Europe 
for  substitutes.  There  is  some  discomfort  in  the  operat- 
ing rooms  during  the  warmer  months,  but  with  a  mini- 
mum of  clothing,  masks,  and  gauze  wristlets  to  take  care 
of  excess  perspiration  and  with  the  normal  ecpianimity 
of  a  surgeon,  one  gets  along  very  nicely  and  can  do 
nearly  as  much  work  as  in  other  climes.  Plenty. of  clean 
air  without  draughts  is  obtainable  l)y  using  double  wire 
screens  on  large  Avindows  near  the  ceiling.  The  usual 
before  and  after  technic  also  obtains  and  the  average 
stay  in  hospital  is  the  same  as  in  Europe  or  xVmeriea. 

It  seems  characteristic  of  the  native  races  wherever 
they  may  be  that  the  surest  way  to  their  confidence  is 
through  efficient  medical  and  surgical  aid.  Once  the  word 
goes  out  that  diseases  hitherto  regarded  by  them  as  hope- 
less can  be  cured,  patients  apply  for  relief  and  accept 
without  question  any  measures  proposed,  a  mental  atti- 
tude greatly  to  their  advantage.  When  we  first  offered 
the  Filipinos  major  surgery,  they  regarded  the  idea  with 

22 


SITRGERV    AND    SURGICAL    OrKRATIONS  23 

horror  until  influenced  by  successful  cases;  then  eighty- 
five  thousand  of  them  applied  during  the  third  year  of  the 
Philippine  General  Hospital  which  was  opened  in  1910. 
Surgically  the  Philippines  are  an  nnseratclied,  virgin 
field.  From  a  superficial  survey  of  five  hundred  thou- 
sand inhabitants  living  outside  of  Manila,  I  o1)tained  data 
of  over  ten  thousand  surgical  cases  and  all  of  the  lesions 
reported  were  the  visible  tumors,  swellings,  and  deformi- 
ties of  the  unclothed  parts  of  the  body. 

In  this  country  and  in  Europe  the  laboratory  is  not 
always  the  essential  feature  in  diagnosis  to  the  extent 
that  it  is  among  a  people  where  the  finding  of  one  definite 
cause  of  illness  is  hardly  ever  sufficient  to  account  for  a 
patient's  condition.  Since  Oriental  and  other  insanitary 
races  have  enjoyed  a  contact  with  Western  civilization, 
and  have  begun  dying  out,  it  is  not  unusual  to  find  a 
single  individual  wdth  malaria,  tuberculosis,  syphilis, 
gonorrhea,  a  drug  habit,  filariasis,  severe  skin  lesions, 
other  sources  of  systemic  disease,  amebas  and  three  or 
four  other  intestinal  parasites  in  addition  to  his  surgical 
atfection,  and  yet  to  find  that  he  is  not  entirely  disabled 
by  any  of  them;  there  is  also  the  ever-present  possibility 
of  an  epidemic  disease  such  as  cholera,  pox  or  plague,  all 
of  wdiich  tends  to  develop  the  successful  medical  man 
into  an  Argus-eyed  individual.  Consequently,  diagnosis 
and  treatment,  at  their  best,  require,  not  only  a  far  greater 
application  and  correlation  of  laboratory  findings  and 
bedside  observations  than  in  our  climes,  but  all  of  the 
general  and  physical  conditions  of  these  peoples  must  be 
appreciated  and  taken  into  consideration  as  well.  The 
fish  and  vegetable  diet,  nonindulgence  in  alcohol  and  the 
placid  existence  led  by  the  majority  of  natives  are  to  their 
advantage.  They  take  anesthetics  quietly  and  react  fa- 
vorably after  severe  operations.  The  average  pulse  is 
lower,  the  blood  pressure  about  the  same  as  in  the  United 
States,  and  the  temperature  about  one  degree  subnormal. 


24  TROPICAL  SURGERY  AXD  DISEASES 

The  anesthetic  in  the  Philippines  is  ether,  given  by  the 
drop  method.  Miss  Emma  Ochsner,  official  anesthetist 
for  a  time  in  Manila,  noted  that  it  requires  yjerhaps  fifteen 
to  twenty  per  cent  more  ether  on  account  of  the  rapid 
evaiioration  than  in  temperate  zone  clinics,  also  that  on 
account  of  the  dark  skins  of  natives,  j^allor  or  conges- 
tions were  not  readily  recognized  and  that  the  hest  index 
to  the  oxidation  of  the  hlood  during  an  anesthesia  was  its 
color  in  the  operation  wound.  It  is  surprising  to  note  the 
persistent  emplopuent  of  chloroform  throughout  tlie  Ori- 
ent. There  is  no  excuse  for  offering  a  scanty  experience 
of  a  few  hundreds  or  even  a  few  thousands  of  chloroform 
anesthesias  without  a  death,  as  justification  for  using 
this  dangerous,  long  since  discarded  drug. 

One  thing  to  be  always  borne  in  mind  concerning  the 
postoperative  treatment  in  dealing  with  the  most  igno- 
rant classes  is,  that  the  surgical  dressings  must  be  ap- 
plied so  that  they  can  not  be  removed;  the  patients  are 
very  apt  to  take  them  off  if  there  is  much  pain  or  dis- 
comfort. 


CHAPTER  III 

DISEASES  OF  THE  HEAD,  NECK,  AND  THORAX 

THE  HEAD  AND  NECK 

Ilarelijj  and  cleft  j^alate  seem  very  common,  probal)ly 
because  these  cases  are  never  repaired.  Incised  wounds 
are  very  frequent  on  account  of  the  universal  use  of  the 
bolo  and  knife  in  settling  disputes.  Several  cases  were 
seen  in  which  the  lips  and  a  piece  of  the  tongue  have 
been  cut  off  as  jDunishment  for  spying  during  military 
times.  In  two  cases  in  which  the  mutilation  resulted  in 
a  pencil-sized  hole  where  the  mouth  had  been,  a  useful 
and  presentable  mouth  was  made  by  plastic  surgery.  The 
anterior  nares  were  found  closed  in  a  number  of  children 
by  the  scars  of  smallpox.  The  angiomas,  cysts,  and  neu- 
ralgias are  not  common.  A  few  cases  of  Recklinghau- 
sen's disease  in  young  people  were  seen  and  removed. 
Impaired  nutrition  of  the  cranial  bones  from  rickets  is 
evidenced  in  the  frequently  noted  cuboidal  head.  There  is 
little  tendency  to  the  general  or  irregular  bony  over- 
growth conditions  occasionally  seen  in  other  climes.  The 
congenital  anomalies,  cephalocele,  encephalocystocele,  ex- 
ternal and  internal  hydrocephalus  are  rather  common  and 
some  striking  cases  are  encountered  (Fig.  1).  Xontrau- 
matic  intracranial  hemorrhages,  tumors,  infectious  cere- 
brospinal fever  and  other  affections  of  the  envelopes  of 
the  brain  itself,  except  traumatic  and  tuberculous  men- 
ingitis and  an  occasional  syphilis  of  the  nervous  system 
are  infrequent. 

In  the  neck,  cysts,  fistulas  and  torticollis  are  rare.  The 
principal  infectious  condition  is  Ludwig's  angina  which 
is  often  met  with  and  is  often  fatal  if  neglected.    Accord - 

25 


26  TROPICAL    SURGERY    AXD    DISEASES 

iiig  to  the  microbic  infection,  wliicli  is  usually  a  mixed 
one,  the  process  in  the  lymph  nodes  is  slow  or  rapid;  it  is 
always  associated  with  carious  teeth  or  some  mucous 
membrane  infection  of  the  oral  cavity.  The  treatment 
is  early  and  free  incision  of  the  overlying  skin  and 
blunt  tunneling  of  the  induration  to  secure  drainage. 
Tuberculous  infection  of  the  lymph  nodes  of  the  neck  is 
one  of  the  commonest  conditions  found  and  it  is  always 
associated  with  infected  tonsils  and  bad  teeth.  Treat- 
ment for  many  years  was  by  excision;  later,  immuniza- 
tion with  Koch's  lymph,  the  opening  of  abscesses  as  they 


Fig.   1. — Encephalocystocele.      (Avithor's  collection.) 


occur  and  instruction   in  antitul)erculosis  hygiene  were 
recommended. 

Of  malignant  growths,  Hodgkin's  disease  is  next  in 
frequency  to  tuberculosis  of  the  neck,  and  in  the  Philip- 
pines, splenic  anemia,  or  Banti's  disease,  probably  a 
splenic  type  of  Hodgkin's  disease,  is  also  frequently- 
encountered.  Xo  treatment,  except  by  x-rays,  in  a  few 
cases,  was  found  effective,  and  attempts  at  excision  only 
aggravated  the  disease.  Bunting  and  Yates '^  recent 
work  holds  out  some  promise  of  relief.    Goiter  in  all  its 


Med 


'Bunting   and    Yates:      The    Rational    Treatment   of    Hodgkin"s    Disease.    Tour.    Am. 
d.  Assn.,   1915,  Ixiv,  No.  24. 


DISEASES    OF    THE    HEAD    AND    NECK  Z( 

varieties  is  very  common  in  the  Philippine  Islands  and 
its  course  and  treatment  does  not  differ  from  the  disease 
in  this  conntry.  As  in  all  unoperated  countries,  some 
extraordinary  cases  are  encountered  (Fig,  2). 


Fig.    2. — Enormous  goiter   with   colloid   and   fatty   degeneration.      (Autlior's   collection.) 


A  few  cases  of  multilocular  lymphatic  cysts  were  seen, 
one  of  enormous  size  that  extended  far  out  from  the 
side  of  the  neck,  overhanging  the  shoulder,  and  extending 
into  the  depths  of  the  neck  and  into  the  axilla  in  a  young 


28  TROPICAL    SURGERY    AND    DISEASES 

Cliinaman;  excision  of  all  of  it  was  imiDracticable,  but 
carbolic  acid  and  tincture  of  iodine  applied  to  the  lining, 
wliicli  section  showed  to  be  endothelial,  resulted  in  a  cure. 
Cancer  is  always  secondary  in  the  neck  excej)t  in  tlie  sali- 
vary glands  in  which  mixed  tumors  are  not  infrequent. 
Lipomas,  single  and  multiple,  also  are  mostly  found  in 
the  neck  in  the  Far  East.    Nothing  unusual  was  noted  in 


Fig.  3. — Cancer  of  the  mouth  and  extension  to  the  neck  in  a  betel   nut  chewer   (1911). 

(Author's  collection.) 


the  diseases  of  the  e^^e,  ear,  nose  and  throat,  or  the  sinuses 
of  the  facial  bones.  In  the  mouth,  tongue,  teeth  and  jaws, 
pathology  was  very  frequent  and  due  to  defective  teeth 
and  lack  of  oral  asepsis.  The  most  common  site  for  can- 
cer is  on  the  side  of  the  buccal  cavity  where  the  betel  nut 
cud  is  held  (Figs.  3  and  4) ;  this  chew  is  made  of  a  slice 


r)T:=;EASI':S    OF    TflK    THORAX  29 

of  betel,  a  nut  of  the  Boii^^a  jjalm,  a  ijiiieli  of  tobacco 
and  some  lime,  all  wrapped  in  a  piece  of  the  acrid  astrin- 
gent buyo  leaf.  The  effect  of  this  fiery  bolus,  which  turns 
the  teeth  blood  red  and  black,  aided  by  lesions  of  the  inner 
cheek,  caused  by  the  sharp  edges  of  decaying  teeth  is  to 
furnish  plenty  of  local  irritation  for  the  develox^ment  of 
a  primary  cancer.     Osteomyelitis,  fluid-containing  cysts, 


' 

% 

-^\:  - j-  i'<* 

Fig.  4. — Cancer  of  the  cheek  and  face  from  primary  cancer  of  buccal   mucosa  in  a  betel 
nut  chewer   (1911).      (Author's   collection.) 

and  epulis  of  the  lower  jaw  were  more  common  than  in 
this  country.     Gangosa  is  described  under  syphilis. 

THE  THORAX 

Perhaps  the  only  diseases  of  the  lungs  and  the  bronchi, 
very  common  in  the  Tropics  and  unusual  or  not  recog- 
nized elsewhere,  are  those  due  to  certain  fungi. 


30  TROPTCAL    SI-Rf;ERY    AXD    DISEASES 

Bronchomycosis 

Castellani,  years  in  Ceylon,  now  of  the  University  of 
Naples,  lias  published  many  cases  since  1905.  He  de- 
scribes a  bronchomycosis  due  to  a  variety  of  fungi  be- 
longing to  the  following  genera:  ''1,  Monilia;  2,  Xocar- 
dia;  3,  Aspergillus,  Sterigmatocystis  penicillinm;  -1,  Mu- 
cor  and  Ehizomincor,  Lichtheimia;  5,  Sporotrichum;  6, 
Undetermined  fungi.  The  symptoms  are  somewhat  sim- 
ilar whatever  fungus  is  the  etiologic  factor.  In  mild 
cases  there  are  signs  of  slight  bronchitis  with  mucopuru- 
lent expectoration,  in  which  the  fungi  are  found.  In 
severe  cases  the  patient  presents  all  the  symptoms  of 
phthisis  with  hectic  fever  and  hemorrhagic  expectoration. 
Mild  cases  may  become  cured  spontaneously;  they  are 
often  benefited  by  potassium  iodide."  He  describes  in 
detail  the  form  of  bronchomycosis  due  to  fungi  of  the 
genus  Monilia;  this  type  of  bronchomycosis  being  ex- 
tremely common  in  Ceylon,  it  has  been  possible  for  him 
to  investigate  it  more  completely. 

Bronchomoniliasis 

Synonyms. — Broncho-oidiosis  Cast;  Bronchoendomy- 
cosis  Cast. 

Definition. — An  infection  of  the  bronchial  mucosa,  due 
to  fungi  of  the  genus  Monilia. 

Etiology. — In  Ceylon,  the  malady  is  generally  due  to 
]\Ioiiilia  tropicalis;  the  same  fungus  is  found  in  cases 
coming  from  Southern  India  and  the  Malay  States,  and 
a  very  similar  one  in  a  ease  that  apparently  contracted 
the  disease  in  Europe.  It  would  appear  that  the  fungus 
is  the  real  cause  of  the  disease,  as  no  other  etiologic 
agents,  such  as  the  tubercle  bacillus,  etc.,  are  found. 
Moreover,  when  the  patient  gets  better,  the  fungus  be- 
comes very  scanty  or  disappears  completely.  In  some 
cases  Castellani  o])served  and  described  thirteen  other 


DISEASES    OF    TFTE    TIIOIIAX 


species  of  Monilia  but  doubts  wlictlici-  all  of  tlieni  are 
pathogenic.  The  infection  niay  take  pU\ce  from  man  to 
man,  and  also,  most  prol)al)ly  by  tlie  fungi  living  sapro- 
phytically  in  natui'e.  Moniliadike  fungi  are  extremely 
connnon  in  Ceylon,  in  tea  dust  for  instance,  and  it  is  Yerj 
probable  that  the  so-called  "tea-factory  cough"  is  a  type 
of  moniliasis,  as  in  such  cases  a  nionilia  is  found  in  the 
sputum,  and  monilia-like  fungi  are  constantly  found  in 
the  tea  dust  of  the  factories.  Moreover,  guinea  pigs,  in 
the  nostrils  of  which  tea  dust  is  regularly  insufflated,  de- 
velop after  a  time  a  moniliasis  of  the  lungs. 

Symptomatology. — A  mild  and  a  severe  type  of  the 
malady  may  be  distinguished.  In  the  mild  type  the 
general  condition  of  the  patient  is  fairly  good,  there  is  no 
fever,  and  he  simply  complains  of  cough.  The  expectora- 
tion is  mucopurulent  and  very  often  scanty;  no  blood. 
The  physical  examination  of  the  chest  will  reveal  a  few 
coarse  moist  rales  or  absolutely  nothing.  The  condition 
may  last  several  weeks  or  months,  and  may  cure  spon- 
taneously, or,  continuing,  may  turn  into  the  severe  type. 
The  severe  type  closely  resembles  phthisis;  the  patient 
becomes  emaciated,  there  is  hectic  fever,  mucopurulent 
and  bloody  expectoration.  Occasionally,  true  hemoi^tysis 
occurs,  a  teaspoonful  or  more  of  bright  blood  being- 
spit  up  at  a  time.  The  physical  examination  of  the  chest 
shows  patches  of  dullness,  fine  crepitations  and  pleural 
rubbing.  This  type  is  often  fatal.  Between  these  two  ex- 
treme types  there  are  cases  of  intermediate  severity,  with 
subcontinuous  and  continuous  fever,  more  or  less  definite 
bronchial,  and  bronchoalveolar  symptoms. 

Prognosis. — The  cases  of  a  mild  type  may  recover 
spontaneously  or  under  appropriate  treatment.  Those 
of  the  malignant  type  usually  end  fatally. 

Diagnosis. — The  diagnosis  of  moniliasis  is  based  on 
finding  the  fungus  in  the  sputum.  It  is  absolutel}"  nec- 
essary that  this  should  be  collected  in  sterile  Petri  dishes 


32  Tr.OPICAL    SI'ROEr.Y    AXD    DISEASES 

and  examined  as  soon  as  possible,  as  sputum  exposed  to 
the  air  becomes  contaminated  with  all  sorts  of  fungi  in  the 
tropics.  In  fresh  preparations  of  the  expectoration, 
spore-like,  roundish  or  oval  cells,  4  to  6  micra,  are  seen, 
and  some  mycelial  particles.  The  fungus  is  Gram-posi- 
tive. To  identify  the  fungus,  cultural  researches  are 
necessary. 

DiFFEREXTiAL  DiAGxosis. — Primary  bronchomoniliasis 
as  described  in  this  chapter,  should  be  distinguished  from 
the  secondary  bronchomoniliasis  occasionally  met  with  in 
cachectic  patients  suffering  from  cancer,  diabetes,  tuber- 
culosis, etc.  In  such  cases  there  is  generally  a  thrush 
of  the  oral  mucosa,  and  the  thrush  monilia  spreads  to  the 
pharynx,  larynx,  and  bronchial  mucosa,  while  in  primary 
bronchomoniliasis  the  oral  mucosa  is  not,  as  a  rule,  af- 
fected. From  pulmonary  tuberculosis  the  condition  is 
distinguished  by  the  absence  of  the  tubercle  bacillus  in 
the  sputum  and  the  negative  animal  inoculations.  Cases 
of  mixed  infection,  however,  tuberculosis  and  moniliasis, 
are  occasionally  met  with,  the  sputum  containing  both 
the  tubercle  bacillus  and  the  monilia  fungus.  Moniliasis 
differs  from  bronchospirochetosis  by  the  absence  of  spiro- 
chetes, from  endemic  hemoptysis  by  the  absence  of  the 
ova  of  Paragonimus  westermani  kerbert. 

Treatment. — ]\li]d  cases  and  those  of  moderate  gravity 
respond  quickly  to  potassium  iodide  (10  to  20  grains), 
given  well  diluted  in  water  or  milk,  three  times  daily. 
When  potassium  iodide  causes  severe  symptoms  of 
iodism,  sajodin  in  the  same  doses  in  cachets  may  be  ad- 
ministered. In  tlie  cases  of  malignant  tyj)e  Castellani  has 
seen  no  imj)rovement  from  the  many  different  treatments 
tried.  Potassium  iodide,  however,  should  always  be  tried 
in  these  cases  as  well  as  balsamics.  The  diet  should  be 
nourishing;  hypophosphates  and  glycerophosphates,  etc., 
may  be  tried  to  keep  up  the  strength  of  the  patient,  as  in 
phthisis. 


CHAPTER  IV 

THE  ABDOMEN 

Xothing-  unusual  was  encountered  in  thirteen  years' 
experience  in  the  Philippines  in  the  surgery  of  the  abdo- 
men and  its  contents,  except  in  the  colon,  liver,  and 
spleen.  Appendicitis,  gall  duct  disease,  gastric  and  duo- 
denal ulcer  were  not  so  frequent  as  in  the  United  States 
and  consequently  s^Tiiptoms  referred  to  the  stomach  were 
not  so  common.  Cancer,  however,  in  its  usual  favorite 
localities  was  frequenth^  observed. 

HERNIA 

In  spite  of  the  fact  that  the  squatting  posture  of  natives 
while  defecating  or  sitting  down,  presses  the  abdominal 
rings  firmly  against  the  thighs,  inguinal  hernia  is  rather 
common  among  the  laboring  classes;  it  has  no  special 
points  of  interest  unless  it  is  that  the  occurrence  of  the 
sliding  variety,  which  was  encountered  many  times,  is 
unusually  frequent.  The  Ferguson-E.  Wyllys  Andrews 
type  of  operation  was  preferred.  During  military  service 
in  Manila  during  1900-1901  I  operated  upon  one  hundred 
cases  among  American  soldiers  and  noted  an  amount  of 
fat  in  the  cord  which  might  lie  described  as  lipomatous 
and  which  required  removal  in  many  cases,  as  at  that 
time  the  Bassini  operation  was  employed.  In  natives  lit- 
tle fat  was  found,  but  the  appendix  was  a  content  of  the 
sac  in  about  three  per  cent,  and  in  three  cases  in  250,  the 
l)ladder  was  found;  femoral  hernia  was  very  rare.  All 
patients  were  kept  in  bed  tliree  weelvs  and  were  cau- 
tioned against  heavy  lifting  or  any  overexertion  for  three 
months  more. 

33 


34  TROPICAL    SURGERY   AXD    DISEASES 

THE  SPLEEN 

The  patliolog}^  and  surgery  of  the  spleen  have  received 
special  attention  at  the  Mayo  Clinic  since  1912,  and  as 
splenic  disease  is  very  common  in  the  Tropics  and  liith- 
erto  neglected  through  lack  of  knowledge  concerning  it, 
as  an  aid  to  tropic  workers,  iDermission  was  secured  to 
use  their  publications  and  several  are  herewith  reprinted 
from  ''Collected  Papers  of  the  Mayo  Clinic,"  to  which 
reference  is  suggested  for  fuller  information.  This  mat- 
ter will  be  found  in  the  appendix.. 

Splenic  Anemia  and  the  Kala-azar 

Splenic  anemia,  Banti's  disease,  or  splenomegalia,  was 
not  uncommon  and  as  a  possible  relation  between  this 
condition  and  Hodgkin's  disease,  which  is  so  common  in 
the  Philippines,  has  been  recently  noted,  these  islands 
might  be  a  good  field  for  investigation.  Operation  was 
obtained  in  only  a  few  cases  and  those  were  mostly  un- 
suitable on  account  of  extensive  adhesions  and  liver  cir- 
rhosis. 

Kala-azar,  ("Kala-jwar,"  Indian  for  ''black  disease"), 
splenic  leishmaniosis  and  internal  leishmaniosis,  caused 
by  the  Leishman-Donovan  protozoan,  probably  identical 
with  the  Herpetomonas,  attacks  especially  tlie  endothe- 
lial cells  of  the  circulatory  system.  This  disease  is  widely 
distributed  in  Asia.  It  is  very  chronic  and  in  the  later 
stages  with  the  enlargement  of  the  spleen  and  liver  re- 
sembles chronic  malaria  in  its  s^anptoms  of  sweating, 
anemia,  general  pains,  skin  pigmentation,  nose  bleed  and 
marasmu-s.  It  is  usually  fatal.  A  iDositive  diagnosis  is 
established  by  splenic  or  hepatic  punctui-e  which  will  usu- 
ally' reveal  the  Leishman-Donovan  bodies  in  large  num- 
bers. Recently  Dr.  Samuel  Cochran  of  Hwai;^'uan,  An- 
hwei,  China,  has  demonstrated  that  the  "bodies"  may  be 
found  in  abundance  in  any  Ijanph  node  in  the  body  and  he 


TirE    ABDOMEX 


35 


usually  takes  the  most  accessible  cervical  node  for  diag- 
nosis. It  has  been  variously  described  under  the  names 
of  infantile,  Indian,  Italian  and  Malta  kala-azar  and  an 
enormous  amount  of  investigation  has  been  made.  It  is 
to  be  regarded  as  infectious  and  eases  should  be  isolated ; 
all  vermin  about  botli  tlic  sick  and  the  well  should  be  de- 
stroyed and  dogs  should  be  closely  inspected,  as  they 
have  a  very  similar  disease. 

Xo  specific  has  been  discovered,  and  treatment  by 
drugs,  principally  quinine  and  arsenic,  has  not  been  sat- 
isfactory. Di  Cristina  and  Caronia^  (1915)  have  applied 
Vianna's  tartar  emetic  method  in  ten  cases  of  internal 
leishmaniosis,  and  report  gratifying  results.  They  gave 
it  intravenously,  injecting  from  0.02  to  0.1  gram  of  a  1 
per  cent  solution  of  the  antimony  and  potassium  tartrate 
on  alternate  days.  Two_of  the  patients  were  moribund. 
Two  others  were  children  and  they  were  much  improved ; 
five  others  were  completely  cured  and  one  died  from  acute 
nephritis;  the  dosage  in  this  nephritis  case  was  less  than 
in  the  others,  so  that,  if  the  medication  w^as  in  any  way 
responsible  for  the  kidney  disease,  the  kidneys  must  have 
been  exceptionally  susceptible.  The  total  amount  ranged 
from  0.06  to  0.84  gram,  given  in  the  course  of  ten  to  forty 
days.  The  children  were  between  one  and  six  years  old; 
the  affection  was  severe  and  of  two  to  eight  niontlis' 
standing. 

Mackie  {BrltisJi  Medical  Jountal,  Xov.  20,  1915,  p.  7-45) 
had  two  prompt  cures  of  kala-azar  by  injections  of  tar- 
tar emetic;  one  case  of  the  lip  and  cheek  and  one  case 
of  the  spleen  and  general:  intravenous  injections  of  4 
to  6  c.c.  of  a  1  per  cent  solution  in  normal  saline  every 
two  or  three  days  were  used;  there  was  some  temper- 
ature after  the  first  two  injections ;  the  treatment  lasted 
about  two  weeks ;  cutaneous  lesions  which  were  slow  in 
healing  closed  after  a  few  applications  of  carbon  diox- 


^G.   di  Cristina  and  G.   Caronia:     Tartar  Knietic   in   Internal    I.eishniaiiiosis.    Pedriatria, 
Naples,   Feb.,    1915,  xxiii,   Xo.   2,   pp.   81-160 


36  TRdPICAL    SUKGEEY    AK^D   DISEASES 

ide  sno^v.  Two  per  cent  antimony  tartrate  ointment 
lias  also  Ijf/en  efficacious.  Gaeliet,  working  in  Persia, 
claims  very  good  i-e suits  Avith  one  or  two  intravenous  in- 
jectious  of  arsenobenzol ;  as  a  rule  one  injection  is  nec- 
essary, lie  says,  but  sometimes  two  are  required  and 
tlii^  cure  is  complete  in  three  to  live  weeks. 

Eoiiers  (Tropical  Disease  Bull. y  vol.  9,  No.  5,  March 
15,  1917)  reported  additional  eases  of  Kala-azar  among 
Europeans  making  18  successfully  treated  by  intra- 
venous injections  of  tartar  emetic.  He  states  that  of 
the  18  consecutive  cases,  13  were  cured;  2  greatly  im- 
I)roved  and  still  under  treatment,  2  improved  and  dis- 
continued treatment  and  one  died  of  phthisis.  Cases 
were  called  cured  when  ''the  fever  has  comiDletely 
ceased  for  two  or  more  months,  together  with  consider- 
able gain  in  weight  and  a  restoration  of  the  blood,  and 
especially  of  the  white  corpuscles  to  the  normal  and  de- 
cided dimiimtion  in  the  size  of  the  spleen.''  Rogers 
suggests  that  in  view  of  his  results,  the  use  of  tartar 
emetic  appears  to  be  worthy  of  further  study  in  human 
trypanosuniiasis  and  sleeiDing  sickness  in  Africa.  The 
injections  a\  ere  continued  two  or  three  months  after  the 
fever  had  ceased  and  only  stopped  as  a  rule  when  the 
body  weight  had  nnich  increased,  the  spleen  become  con- 
siJeralily  re(lnr(M.].  tlie  l)lo':)d  had  approached  or  reached 
normal  anil  tlie  parasites  had.  disap^Deared  from  the 
spleen.  It  is  thought  that  the  period  of  treatment  may 
be  reduced  liy  a  more  rapid  increase  of  dosage.  Treat- 
ment in  adults  is  i)eoTm  with  -4  e.c.  of  the  2  per  cent  solu- 
tion, 6  c.c.  are  oivHH  at  the  second  injection  and  at  each 
subsequent  injection  one  c.c.  is  added,  if  no  toxic  satqi^- 
toms  supervene,  up  to  8  or  10  c.c. 

See  page  128  for  CasteUani's  treatment  under  Yaws. 

A  great  many  cases  of  abscess  of  the  spleen  have  been 
reported  from  China,  several  of  which  recovered  after 
drainage,  out  no  pathology  was  given. 


THE    COLOX  6i 

THE  COLON 

Entamebic  Dysentery 

This  disease  competes  witli  malaria  for  the  honor  of 
being  the  most  ubiquitous  of  endemic  tropical  diseases. 
Americans  first  became  acquainted  with  entamebic  dysen- 
tery in  1898  during  tlieir  subjugation  of  the  Philii^pines 
and  the  respect  soon  acquired  for  it  was  such,  that  in 
the  early  days,  although  every  man  was  greatly  needed 
for  the  military  operations,  the  discovery  of  a  single 
ameba  of  any  sort  in  the  stools  resulted  in  an  immediate 
transfer  of  the  patient  to  the  r'nited  States.  The  only 
literature  then  available  recognized  but  one  variety  of 
ameba  and  gave  but  one  prognosis,  death  within  a  short 
time  or  at  the  latest  in  two  or  three  years  (Osier).  Prob- 
ably every  man  of  our-  entire  expeditionary  force  of 
over  65,000  men  suffered  at  one  time  or  another  from 
dysenteric  boAvel  trouble  and  it  was  the  princi])al  cause 
of  disability.  In  recent  years  this  disease  is  being  found 
in  almost  every  state  in  the  Union.  An  enormous  amount 
of  investigation  has  been  done  by  pathologists  and  pro- 
tozoologists  notably  by  Schaudinn  (1903),  Musgrave  and 
Clegg  (1904),  Craig'  (1905),  Vedder  (1906),  Darling 
(1912),  and  later  by  Walker  and  Sellards  (1910-1913),  to 
determine  the  pathogenicity  of  the  various  species  and 
their  eti<^logic  relationship  to  endemic  dysentery.  The 
recent  experiments  by  AValker  and  Sellards-  conclusively 
established  the  etiology;  they  differ  from  those  hitherto 
performed:  "(1)  in  the  number  of  comparative  tests 
made  of  different  species;  (2)  in  that  experiments  have 
been  more  carefully  controlled  and  especially  in  that  the 
species  of  ameboid  organisms  fed  to,  and  recovered  from, 
the  experimental  animal  in  every  case  have  been  deter- 
mined; and  (3)  in  the  fact  that  the  experiments  have  been 


-Walker,   E.  L.,   and   Sellards,   A.   \\'. :      Experimental   Entamoeb'c   Dysentery,   Philip- 
pine Jour.    Sc,   Sec.  B,   Tropical   Medical,   August,   1913,  viii.  No.   4. 


do  TROPICAL  SURGERY  AND  DISEASES 

made,  not  upon  the  lower  animals,  but  upon  man. ' '  These 
experiments  showed:  that  the  cultivable  amebas  are  non- 
pathogenic; that  the  Entameba  coli  is  nonpathogenic; 
and  that  Entameba  histolytica  is  the  essential  etiologic 
factor  in  endemic  tropical  dysentery  and  that  ''Entameba 


-    ■     - -^ ._.J 

Fig.  S. — Colon.     Multiple  areas  of  necrosis  in  acute  entamebiasis.     (Author's  collection.) 


tetragena  Viereck"  is  identical  with  Entameba  histoly- 
tica, and  "tetragena"  cysts  are  developed  in  the  life  cycle 
of  Entameba  histolytica;  that  it  is  a  strict  or  obligatory 
parasite  and  can  not  be  cultivated  outside  of  the  body 
and  that  the  average  incubation  period  of  the  dysentery 


THE    COLOIiT  39 

lias  l)een  64.8  days.  All  of  the  experimental  dysenteries 
were  obtained  after  ingesting  Entanieba  histolytica  from 
normal  stools  of  '^carriers." 

Diagnosis 

Clinical     Symptoms. — Physical     weakness,     loss     of 
appetite     and     digestive     disturbance     with     or     with- 


■--•  •^>  aum 


■T^. 


Fig.    6. — Multiple   ulcerations    severe   chronic   entamebiasis.      (Author's   collection.) 

out  diarrhea  usually  indicate  the  onset  of  parasitism  of 
the  colon  by  Entameba  histolytica,  but  the  relation 
to  the  local  infection,  in  which  abdominal  pain  and 
tenesmus  may  be  entirely  absent,  is  so  often  overlooked 


40  TROPICAL    SUEGEPvY    AND    DISEASES 

that  many  cases  are  treated  for  the  reflex  gastric  s^onp- 
toms.  The  liver  at  times  becomes  congested,  edematous, 
and  swollen ;  back  pressure  in  the  portal  system  aggra- 
vates the  primary  colonic  disease  (Figs.  5  and  6),  and  it 
in  turn  disturbs  the  liver  f^till  more  and  the  patient  has 
^'tropical  liver.'.'  WliQii  the  flux  is  not  marked^  and,  as 
too  often  happens;  a  diagnosis  is  not  made,  these  cases, 
when  they  die,  afford  examples  of  what  Niemeyer  calls 
'' mortifying  postmortem  disclosures."  The  majority  of 
cases,  however,  have  frequent,  mucoid  and  bloody  stools 
at  the  outset  and  vdien  the  disease  is  well  established, 
their  main  characteristic  is  fluidity. 

Walker  ^iid  Sellards  acquired  information  of  the  great- 
est value  /for  the  diagnosis,  treatment,  and  prophylaxis 
of  entamebic  dysentery  as  follows:  "(1)  It  will  be  pos- 
sible to  make  an  accurate  laboratory  diagnosis.  (2)  The 
distinction  between  the  pathogenic  and  the  harmless  enta- 
meba  having  been  established,  there  will  no  longer  exist 
an  excuse  for  the  indiscriminate  treatment  of  all  persons 
who  show  entamebse  in  their  stools.  (3)  The  relatively 
long  incubation  period  and  the  ability  to  diagnose  latent 
infections  make  it  possible  to  anticipate  Avith  treatment 
an  attack  of  entamebic  dysentery.  (4)  Since  there  is 
evidence  that  ipecac  treatment,  which  is  very  efficient  in 
relieving  attacks  of  entamebic  dysentery  and  causing  the 
entamebee  to  disappear  temporarily  from  the  stools,  does 
not  always  kill  all  of  the  entamebse  in  the  intestine,  treat- 
ment should  always  be  controlled  by  stool  examinations 
for  Entamebse  histolytica.  By  this  precaution,  relapses,  so 
common  in  entamebic  dj^sentery,  can  be  forestalled.  (5) 
The  following  data  have  been  acquired  upon  which  to 
base  a  rational  prophylaxis  of  entamebic  dysentery:  (a) 
Entameba  histolytica  is  the  essential  etiologic  agent  in 
the  disease,  (b)  The  specific  entameba  is  an  obligatory 
parasite,  and  can  not  propagate  outside  of  the  body  of  it-s 
host,     (c)  The  motile  forms  of  this  entameba,  which  are 


THE    COLON  41 

passed  in  the  l)l<)0(ly  mucous  stools  in  acute  dysentery, 
quickly  die  and  disintegrate  and  are  probably,  under 
natural  conditions,  incapable  of  withstanding  passage 
through  the  human  stomach,  (d)  In  consequence  of  the 
relatively  long  incubation  period  of  entamebic  dysentery, 
the  prevalence  of  chronic  and  latent  infections,  and  the 
frequent  failure  of  treatment  to  kill  all  of  the  entamebse 
in  the  intestine,  carriers  of  Entameba  histolytica  are  com- 
mon in  endemic  regions,  (e)  These  carriers  are  con- 
stantly passing  in  their  stools  large  numbers  of  the  re- 
sistant, encysted  stage  of  Entameba  histolytica.  (6) 
These  facts  make  it  probable  that  carriers  of  Entameba 
histolytica  constitute  the  chief,  if  not  the  sole,  agents  in 
the  dissemination  of  entamebic  dysentery.  (7)  Prophy- 
lactic measures  should,  therefore,  be  directed  toward  car- 
riers of  Entameba  histolytica,  and  should  include  the  fol- 
lowing: (a)  The  identification  of  carriers  of  Entameba 
histolytica  by  the  microscopic  examination  of  the  stools 
of  convalescents,  household  servants,  and  other  suspects 
or  persons  whose  employment  or  associations  make  them 
particularly  dangerous  to  the  public  health,  (b)  The 
sanitary  disposal  of  feces,  (c)  The  treatment,  controlled 
by  microscopic  examination  of  their  stools,  of  all  carriers 
of  Entameba  histolytica.  (8)  Since  the  incubation  period 
of  entamebic  dysentery  is  usually  long  and  latent  infec- 
tions are  common,  the  most  efficient  personal  prophylac- 
tic measure  is  frequent  stool  examinations,  as  an  index  for 
treatment,  of  all  persons  residing  in  endemic  regions,  in 
order  to  distinguish  the  resting  and  encysted  entameb^e 
of  the  chronic  and  latent  infections,  w^iich  stage  furnishes 
the  most  unequivocal  characters  for  the  differentiation  of 
the  pathogenic  Entameba  histolytica  from  the  harmless 
Entameba  coli." 

Upon  the  correct  microscopic  diagnosis  of  the  specific 
organism  depend  the  treatment  and  prophylaxis;  as 
this    identification   has    been    subject    to    many    errors 


42  TROPICAL    SURGERY    A:ND    DISEASES 

and  tlie  extensive  practical  experience  gained  by  AValker 
has  demonstrated  that  the  microscopic  diagnosis  can  be 
made  with  certainty,  the  subjects  as  treated  by  him  fol- 
low in  full. 

''The  material  for  the  microscopic  examination  for  En- 
tameba  histolytica  should  be  a  stool  obtained,  contrary 
to  the  prevailing  practice,  without  the  previous  admin- 
istration of  a  purgative.  In  stools  obtained  after  a  pur- 
gative, Entameba  histolytica,  if  present  in  the  fluid  stools, 
is  in  a  preencysted  stage  at  which  it  most  closely  resem- 
bles the  nonpathogenic  species,  Entameba  coli;  conse- 
queiith^,  a  differential  diagnosis  between  the  two  species 
is  difficult  and  often  impossible. 

"It  may  be  objected  that  Avithout  a  purgative,  infec- 
tions Avith  Entameba  histolytica  will  frequently  be  over- 
looked. However,  such  is  not  the  case.  It  has  been  my  ex- 
perience in  following  many  cases  of  entamebic  infection 
with  daily  stool  examinations,  including  cases  doubly  in- 
fected with  Entameba  histolytica  and  Entameba  coli,  that 
the  entamebse  are  rarely  absent  from  the  normal  stools 
several  successive  days  and  that  Entameba  histolytica  is 
more  constantly  present,  and  usually  present  in  larger 
numbers,  in  the  stools  of  infected  persons  than  is  En- 
tameba coli.  In  930  microscopic  examinations  made  of 
stools,  without  the  previous  administration  of  a  purga- 
tive, from  men  known  to  be  parasitized  with  Entameba 
histolytica,  and  who  were  not  undergoing  treatment,  the 
entameba)  were  found  664  times,  or  in  71.39  per  cent;  that 
is,  in  nearly  3  out  of  every  4  of  such  examinations.  More- 
over, the  negative  results  were  based  on  the  examination 
of  a  single  coverslip  which  was  often  hurriedly  made. 
The  examination  under  similar  conditions  of  303  stools 
of  men  known  to  be  parasitized  with  Entameba  coli 
showed  the  entamebae  in  171,  or  56.44  per  cent  of  the  ex- 
aminations; in  other  words,  in  about  1  out  of  every  2  of 
such  examinations. 


THE    COLOiSr  4:d 

*'A  further  objection  that  may  be  raised  to  the  examina- 
tion of  formed  stools,  is  the  fact  that  in  such  stools  usually 
only  encysted  entamebcP  are  to  be  found.  It  is  an  opinion 
generally  held,  and  which  is  supported  by  the  statement 
in  all  textbooks,  that  a  positive  diagnosis  of  entamebic 
infection  should  never  be  made  unless  motile  entamebas 
are  observed.  It  is  of  the  greatest  importance,  however, 
for  the  diagnosis  of  clironic  and  latent  infections  that  one 
should  be  able  to  distinguish  resting  and  encysted  en- 
tamebre  from  other  bodies  found  in  feces  and  to  differ- 
entiate the  cysts  of  Entameba  histolytica  from  those  of 
Entameba  coli.  This  can  be  done  with  certainty  by  the 
experienced  jorotozoologist.  The  majority  of  the  1,233 
examinations  mentioned  in  the  preceding  paragraph  were 
made  of  formed  stools  containing  nonmotile  and  encysted, 
chiefly  encysted,  entameb^e.  Moreover,  it  is  the  encysted 
stage  of  the  entameba  that  furnishes  the  most  unequivo- 
cal characters  for  the  differentiation  of  the  pathogenic 
Entameba  histolytica  from  the  harmless  Entameba  coli. 

''In  the  examination  of  liver  abscess  pus  for  Entameba 
histolytica,  the  pus  first  obtained  after  the  operation 
usually  does  not  contain  entamebse;  frequently  they  ap- 
pear in  the  pus  from  the  drainage  tube  only  after  several 
days.  The  explanation  of  this  is  to  be  found  in  the  fact 
that  the  entamebse  are  not  found  in  the  pus  of  the  abscess, 
but  only  in  the  tissues  of  its  walls.  Consequently,  it 
is  only  when  the  walls  of  the  abscess  begin  to  slough 
olf  that  the  entamebse  appear  in  the  drainage  from  the 
abscess.  Therefore  a  negative  diagnosis  of  entamebic 
liver  abscess  should  never  be  made  except  after  negative 
examinations  obtained  for  several  successive  days  after 
operation. 

''Dysenteric  or  diarrheal  stools  should  be  examined  as 
soon  as  possible  after  they  are  passed,  since  the  motile 
entameb?e  present  in  such  stools  quickly  die  and  disin- 
tegrate.    On  the  other  hand,   in  the  formed  stools  of 


44  TROPICAL    SURGERY    AND    DISEASES 

chronic  and  latent  infections,  the  encysted  entamebse 
l^ersist  unchanged  for  days,  and  consequently  the  exam- 
ination can  be  made  at  one's  leisure. 

' '  In  making  the  examination,  a  small  platinum  loopf ul 
of  the  fluid  or  semifluid  material  should  be  placed  on  a 
microscope  slide  and  the  cover-glass  dropped  upon  it. 
Slight  pressure  may  be  exerted,  if  necessary,  upon  the 
cover-glass  with  the  forceps  to  cause  the  material  to 
flow  as  a  thin  film  between  the  cover-glass  and  slide.  If 
the  stools  be  more  or  less  formed,  a  small  drop  of  water 
should  be  placed  upon  the  slide  and  a  minute  portion  of 
the  stool  rubbed  ui^  in  it,  forming  a  fairly  thick  suspen- 
sion of  the  feces  in  the  water,  upon  which  the  cover-glass 
should  be  placed.  A  satisfactory  preparation  must  be 
thin,  but  there  should  not  be  an  excess  of  fluid  which  will 
permit  the  cover-glass  to  float  about  when  the  oil-immer- 
sion objective  is  applied  to  it.  A  warm  stage  is  not  neces- 
sary for  making  the  examination. 

''The  ad^'antage  of  a  preliminary  examination  of  the 
preparation  with  low  magnification  (Leitz  3  to  Zeiss  AA 
objective)  can  not  be  overestimated.  It  enables  the  ex- 
aminer to  make  a  rapid  survey  of  the  whole  preparation 
and  to  pick  out  the  individual  entameb;©  for  ex- 
amination with  the  oil-immersion  objective.  When  the 
entamebse  are  few  in  the  preparation,  they  can 
be  found  with  difficulty,  if  at  all,  with  higher  mag- 
nification. AVith  a  Leitz  3  or  Zeiss  AA  objective  and 
a  3  ocular,  the  entamebge  appear  as  round,  oval, 
or  irregular,  colorless,  and  refractive  dots  which  with 
proper  focusing  stand  out  distinctly  in  the  back- 
ground of  the  preparation.  Practical  experience  will  en- 
able the  microscopist  to  distinguish  them  from  certain 
other  bodies  that  are  met  with  in  stools.  By  applying 
the  oil-immersion  objective — most  conveniently  used  with 
the  dry  objective  on  a  revolving  nosepiece — to  every  body 
in  the  preparation  that  looks  suspicious  under  low  magni- 


THE    COLON  45 

fication,  this  oxpericnce  will  soon  be  attained.  Indeed,  it 
is  not  only  possible  for  the  experienced  microscopist  to 
identify  an  entameba  with  the  low  nui^'nification,  but  to 
distinguish  a  cyst  of  Entameba  histolytica  from  one  of 
Entameba  coli  with  a  considerable  degree  of  certainty  by 
the  difference  in  its  size  and  refractiveness.  A  suspected 
entameba,  having  been  located  in  the  preparation  with 
the  low  power  objective,  should  then  be  examined  with 
the  K2  oil-immersion  objective.  With  this  magnification 
the  entamebffi  present' certain  morphologic  characters  that 
enable  the  experienced  investigator  to  identify  them, 
whether  they  be  in  the  motile,  resting,  or  encysted  stage. 
The  motile  forms-  will  give  little  difficulty,  even  to  the 
novice,  since  their  movements  are  characteristic. 

''The  resting  entameba  is  distinguished  from  other 
bodies  found  in  the  stool  by  its  size,  distinctness,  regu- 
larity of  contour,  degree  of  refractiveness,  and  especially 
by  its  nuclear  structure.  The  entamebse  vary  in  size 
within  considerable  limits,  but  are  usually  from  20  to  30 
microns  in  diameter.  They  are,  therefore,  larger  than 
pus  cells,  or  other  protozoa,  with  the  exception  of  Balan- 
tidium  coli,  that  are  found  in  the  stools  of  man.  They  are 
also  more  refractive  than  pus,  epithelial,  or  other  cells 
found  in  the  stools.  The  nuclear  structure  of  tlie  enta- 
mebse  is  particularly  characteristic.  The  unencysted  en- 
tamebse  possess,  unless  in  the  process  of  division,  only  a 
single  nucleus.  This  nucleus  is  round,  or  occasionally 
slightly  oval  or  irregular,  small  with  reference  to  the 
size  of  the  cell,  and  appears  not  solid  but  as  a  refractive 
ring  (Fig.  7 — 3,  5,  6,  7).  This  relatively  small,  ring- 
shaped  nucleus  appears  to  be  absoluteh"  diagnostic  of  an 
'entameba.  Only  one  other  kind  of  cell  observed  in  stools 
possesses  a  nucleus  in  any  way  resembling  that  of  an 
entameba.  This  is  an  epitheloid  cell,  sometimes  found  in 
mucous  stools,  which  has  a  ring-form  nucleus  relatively 
much  larger  than  that  of  an  entameba,  occupying  one- 


46  TROPICAL    SURGERY    AISTD    DISEASES 


Fig.  7. 

(From  water-color  drawiugs  by  Teodosio  S.  Espiuosa) 
The  illustrations  in  Fig.  7  are  all  drawn  from  fixed  and  stained  prepara- 
tions at   the  magnification   of  Zeiss  140   oil-immersion   objective,   ocular   3, 
and  tube  length  of  160  millimeters,  and  with  the  aid  of  a  camera  lueida. 

1.  Motile   form    of    a   typical   Ameia,   cultivated   from    the    Manila    water 

supply.  Note  the  small  size,  central  arrangement  of  the  chromatin 
in  the  nucleus,  and  the  contractile  vacuole. 

2.  Encysted  form  of  the  same  species  of  Ameia.     Note  the  small  size  and 

single  nucleus  with  central  arrangement  of  the  chromatin. 

3.  Motile  form  of  Entameba  coli,  from  the  stool  of  a  healthy  person.     Note 

the  dense,  granular  structure  of  the  cytoplasm,  the  relatively  large 
amount  of  chromatin  and  its  peripheral  arrangement  in  the  nucleus. 

4.  Encysted  form  of  Entameia  coli,  from  the   stool  of  a  healthy  person. 

Note  the  large  size,  the  relatively  thick  cyst  wall,  the  8  ring-form 
nuclei,  and  the  absence  of  ' '  chromidial  bodies. ' '" 

5.  Motile  form  of  Entameia  liistolytica,  from  the  stool  of  an  acute  case 

of  entamebic  dysentery.  Note  the  reticulated  structure  of  the  cyto- 
plasm and  the  scanty  chromatin  in  the  ring-form  nucleus. 

6.  Tlie  "tetragena"  type  of  motile  Entameba  liistolytica,  from  a  chronic 

case  of  entamebic  dysentery.  Note  the  structure  of  the  nucleus. 
It  contains  a  heavier  peripheral  ring  of  chromatin — a  part  of  which 
is  detached  from  the  nuclear  membrane — than  in  the  tj-pical  histo- 
lytica;  and  there  is  a  central  karyosome,  consisting  of  a  central 
granule  surrounded  by  a  circle  of  chromatin  granules. 

7.  The  preencysted  stage  of  Entameba  histolytica,  from  a  ''carrier"  case. 

Note  the  small  size,  dense  cytoplasm,  and  heavy  peripheral  ring  of 
chromatin  in  the  nucleus,  which  causes  it  to  resemble  a  small 
Entameba  coli. 

8.  Encysted   form   of   Entameba   histolytica,   from   a   convalescent   case   of 

entamebic  dysentery.  Note  the  small  size,  the  cyst  wall,  the  4  ring- 
form  nuclei,  and  the  ' '  chromidial  body. ' ' 


THE    COLON 


Fig.  7.— Typical  examples  of  Ameba  and  Entameba.     (Walker  and  Sellards:     Entamebic 
Dysentery,  Philippine  Journal  of  Science,  vol.  vui,   No.   4.) 


48  TROPICAL    SURGEEY   AND   DISEASES 

fourth  to  one-half  of  the  cell.  While  an  entameba  may 
occasionally  be  observed  with  an  abnormally  large  nu- 
cleus, probabl}^  preparatory^  to  division,  the  nucleus  never 
approaches  the  size  of  the  nucleus  of  the  epitheloid  cell. 
The  latter  cells  are  also  less  refractive  and  granular  than 
entameb^e. 

"Tlie  encysted  entameba  is  round  or  slightly  oval, 
more  refractive  than  the  resting  or  motile  stage,  and  is 
surrounded  by  a  more  or  less  distinct  cyst  wall.  The 
nuclear  structure  here  also  is  characteristic.  The  cyst 
contains  several  (from  2  to  8,  depending  upon  the  species 
of  entameba  and  the  stage  of  development  of  the  cyst) 
ring-form  nuclei  usually  smaller  than,  but  of  the  same 
structure  as,  the  nucleus  of  the  motile  entameba  (Fig. 
7-4,8): 

' '  The  technic  and  descriptions  so  far  given  refer  to  the 
examination  of  living  entamebse  in  fresh  stools.  This 
method  of  stool  examination  of  entamebas  is  the  quickest 
and  for  general  purposes  of  diagnosis  the  most  satisfac- 
tory. The  preparation  of  stained  specimens  takes  more 
time  and  a  more  extensive  technic,  and  certain  distinctive 
characters  of  the  entameba  are  lost  in  the  fixed  and 
stained  preparation.  On  the  other  hand,  staining  some- 
times assists  in  bringing  out  the  details  of  nuclear  struc- 
ture, and  is  necessary  for  making  permanent  prepara- 
tions of  entamebae, 

*'The  technic  of  fixing  and  staining  entameba  which 
has  given  the  most  uniformly  satisfactory  results  is  as 
follows:  A  thin  smear  of  the  fresh  feces  or  liver  abscess 
pus  is  made  on  a  cover-glass,  fixed  in  sublimate-alcohol 
mixture  or  Zenker 's  fluid  for  from  five  to  fifteen  minutes, 
thoroughly  washed  in  distilled  water,  stained  in  aqueous 
alum  hematoxylin  from  three  to  five  minutes,  washed  in 
distilled,  water,  passed  through  successive  grades  of  ab- 
solute alcohol,  cleared-  in  xylol  or  oil  origanum,  and 
mounted  in  xylol  balsam.    All  of  the  stages  of  this  process 


TPTE   COLOlSr  49 

are  most  conveniently  carried  out  by  floating  the  cover- 
glass,  preparation  downward,  upon  the  surface  of  the 
different  liquids  contained  in  watch  glasses.  The  prep- 
arations should  be  fixed  moist  and  should  not  be  allowed 
to  become  dry  throughout  the  process  of  staining  and 
mounting. 

''The  sublimate-alcohol  mixture  consists  of  2  parts  of 
a  saturated  aqueous  solution  of  mercuric  chloride  and  1 
part  of  absolute  alcohol.  The  sublimate  solution  should 
be  saturated  warm  and  should  be  kept  in  stock.  The 
absolute  alcohol  should  be  added  in  proper  proportion 
only  at  the  time  of  using,  because  alcohol  evaporates  and 
the  solution  changes  in  standing. 

''The  aqueous  alum  hematoxjdin  has  the  following 
composition: 

Hematoxylin  crystals    ■  1 

Saturated  aqueous  solution  of  ammonia  alum       100 

Distilled  water  300 

Thymol  a  crystal 

"The  hematoxylin  crystals  are  dissolved  in  the  water 
by  the  aid  of  heat,  and  the  other  substances  added  to 
the  solution.  The  stain  should  be  ripened  for  from  i\ 
week  to  ten  days  in  a  flask  or  bottle  loosely  plugged  with 
cotton.  It  is  then  readj^  for  use  and  should  be  kept  in  a 
tightly  stoppered  bottle  away  from  the  light.  It  Avill 
keep  in  good  condition  for  several  months. 

"Bodies  that  are  liable  to  be  mistaken  for  entamebiie  in 
the  stools  include  air  bubbles,  fat  globules,  starch  or  pro- 
tein grains,  pus  and  epithelial  cells  of  the  host,  and  cer- 
tain unicellular  vegetable  organisms.  Of  tliese,  air  bub- 
bles, fat  globules,  and  starch  or  protein  granules  of  un- 
digested food,  while  possibly  deceptive  with  low  magni- 
fication, should  from  their  structure  cause  no  difficulty 
when  examined  with  high  magnification.  Stools  contain- 
ing mucus  or  pus  often  contain  many  cells  which  are 
confusing  to  the  inexperienced  microscopist.    It  will  as- 


50  TROPICAL    SUEGEEY   AND    DISEASES 

sist  the  observer  if  he  remembers  that  these  pus  and 
epithelial  cells  with  few  exceptions  are  distinctly  smaller 
than  entamebtTe.  It  will,  therefore,  be  necessary  only  to 
take  into  consideration  cells  which,  when  viewed  with  the 
low  magnification,  are  distinctly  larger  than  the  average. 

''In  feces  containing  pus  there  are  sometimes  present 
large  round  cells  of  uncertain  identity  which  in  size  and 
general  appearance  closely  resemble  resting  or  encysted 
entamebse.  The  cells  contain  from  one  to  several  small, 
round  or  irregular,  refractive,  nucleus-like  bodies  that 
stain  like  chromatin.  It  is  possible  that  they  are  cells 
showing  degenerative  changes  with  fragmentation  of  the 
nucleus.  These  cells  are,  however,  readily  distinguished 
with  high  magnification  from  entamebEe  by  the  structure 
of  the  nucleus-like  bodies,  which  are  not  ring-form,  but 
solid  chromatin  masses.  Motile  forms  of  entameba  also 
will  be  frequently  found  in  such  stools,  which  will  aid  in 
the  diagnosis. 

"Certain  unicellular  vegetable  organisms  known  as 
Blastoc3'tis  hominis  BrumiDt,  which  are  believed  to  be 
allied  to  the  yeasts,  are  found  rather  frequently  in  the 
stools  of  man  in  the  Tropics.  Smaller  forms  of  these  cells 
have  been  mistaken  for  the  cysts  of  Trichomonas  intesti- 
nalis,  and  the  larger  forms  simulate  the  encysted  enta- 
mebffi  very  closely  in  size  and  general  appearance.  They 
are,  however,  slightly  less  refractive  than  the  cysts  of 
Entameba,  and  can,  therefore,  be  distinguished  by  the 
experienced  observer,  even  with  low  magnification.  Un- 
der high  magnification  tliej  are  seen  to  have  a  wholly 
different  structure  from  the  cysts  of  Entameba.  They  are 
round,  oval,  or  slightly  irregular,  and  possess  a  distinct 
wall.  The  protoplasm  is  restricted  to  several  narrow  seg- 
ments of  the  cell,  and  contains  from  one  to  several  gran- 
ules staining  like  chromatin.  The  main  body  of  the  cell  is 
filled  with  a  homogeneous,  hyaline,  slightl}^  refractive, 
and  often  faintly  yellow  mass,  the  nature  of  which  is 


THE   COLOlSr  51 

doubtful,  but  it  probably  represents  reserve  food  sub- 
stance. 

"An  examination  of  Figs,  3  to  <5  in  Fig.  7  Avill  give  a 
good  idea  of  the  general  morphology  of  the  entamebfe. 
Figs.  1  and  2  show  the  motile  encysted  stages  of  a  typical 
nonparasitic  ameba  for  comparison  with  the  entameba. 

"The  differentiation  of  Entameba  histolytica  from  En- 
tameba coli  depends  upon  certain  morphologic  characters 
of  the  two  species  which  are  very  distinctive  at  certain 
stages,  but  less  distinctive  at  other  stages,  of  the  develop- 
ment of  the  two  species.  These  stages  of  the  development 
of  the  parasites  are  correlated  with  the  clinical  manifes- 
tations of  the  infection  and  especially  with  the  consistence 
of  the  stools  of  the  host.  Therefore,  the  comparative 
morphology  of  Entameba  histolytica  and  Entameba  coli 
are  most  conveniently  discussed  in  relation  to  the  nature 
of  the  stools  in  which  they  are  found;  nameh^,  (1)  in 
dysenteric  stools,  (2)  in  diarrheal  stools  and  stools  after 
a  purgative,  and  (3)  in  formed  stools. 

1.  Ix  Dysexteeic  Stools 

"Both  Entameba  histolytica  and  Entameba  coli  occur 
only  in  the  motile  stage  in  dysenteric  stools;  and,  when 
double  i)arasitization  exists,  Entameba  histolytica  is 
usually  the  more  numerous  in  such  stools. 

"Size. — The  size  of  both  histolytica  and  coli  are  sub- 
ject to  wide  variations,  and  little  dependence  can  be 
placed  on  this  characteristic  for  diagnostic  purposes.  In 
dj^senteric  stools  histolytica  often  appears  larger  than 
coli  (Fig.  7 — 3  and  5).  That  this  larger  size  of  histolytica 
is  only  apparent,  and  not  real,  is  probable  from  the  fact 
that  in  the  encysted  stage  (the  onl.y  stage  in  which  reliable 
measurements  can  be  made)  histolytica  is  almost  invari- 
ably smaller  than  coli  (Fig.  7 — 4  and  <S).  This  apparently 
larger  size  of  motile  histolytica  is  probably  connected  with 


52  TROPICAL    SUEGEEY    AND    DISEASES 

tlie  more  active  movements  of  this  species;  while  coli  is 
sluggishly  motile  and  tends  to  retain  a  more  or  less 
spherical  shaj)e,  histolytica  is  activel}^  motile  and  is  ex- 
tended flat  over  the  surface  of  the  substratum. 

''Shape. — Entameba  histolytica,  being  more  actively 
motile  than  Entameba  coli,  presents  a  more  varied  forr.a 
to  the  observer.  While  coli  is  nsualh-  round,  oval  or 
slightly  irregular,  histolytica  is  more  often  long,  oval, 
ligulate  or  irregular  in  fresh  dysenteric  stools. 

"Appearance. — Entameba  histolytica  is  hyaline  and 
feebly  refractive,  while  Entameba  coli  is  more  porcela- 
neous  and  refractive  in  appearance. 

"Edotility. — The  ameboid  movements  of  Entameba  his- 
tol5^tica  are  very  active  in  fresh  dysenteric  stools,  and  the 
motility  of  this  species  often  persists  for  some  hours 
after  the  stool  has  become  cold.  On  the  other  hand,  the 
movements  of  Entameba  coli  are  always  sluggish,  and  all 
motility  is  usually  soon  lost  in  cold  stools. 

"Cytoplasm. — The  cytoplasm  of  Entameba  histolyt- 
ica is  homogeneous,  and  in  the  stained  entameba  is  seen 
to  have  a  coarsely  reticulated  structure  (Fig.  7 — 3).  In 
cold  stools  it  frequently  appears  much  vacuolated.  Con- 
trarj"  to  the  description  given  by  some  authors,  there  is 
no  true  distinction  to  be  seen  between  ectoplasm  and  en- 
toplasm  in  the  resting  entameba.  Individual  entamebse, 
which  contain  granular  material  from  partly  digested 
food,  sometimes  present  the  appearance  of  a  granular 
entoplasm.  In  motile  histolytica  the  extended  pseudopods 
may  present  a  more  dense,  hyaline  appearance  than  the 
reticulated  body  of  the  cytoplasm.  The  cytoplasm  of  his- 
tolytica ma}^  contain  various  cells,  including  red  blood 
corpuscles,  of  its  host.  On  the  other  hand,  the  cytoplasm 
of  Entameba  coli  is  more  granular  in  appearance  (Fig. 
7 — .5).  A  hyaline  ectoplasm  is  apparent  only  in  the  pseu- 
dopods of  the  motile  entameba.     The  cytoplasm  of  coli 


THE    COLON  53 

more  often  contains  l)acterja,  .starcli  and  ])rot(^iii  ,^-raiiis, 
and  other  del3ris  from  the  feces  than  cells  from  the  body 
of  its  host.  The  absence  from  the  cytoplasm  of  red  blood 
corpuscles  and  other  cells  of  its  host  may  result  rather 
from  the  fact  that  coli  is  a  strict  commensal  and  is  more 
often  found  in  nondysenteric  stools  than  from  its  incapac- 
ity to  ingest  red  blood  corpuscles. 

''Nucleus. — The  nucleus  of  Entameba  histolytica  is 
usually  indistinct  in  the  motile  organism,  especially  if  it 
be  actively  motile  or  much  vacuolated.  In  the  latter  case 
it  is  sometimes  impossible  to  distinguish  the  nucleus 
from  the  vacuoles.  In  stained  preparation  the  nucleus  of 
histolytica  is  seen  to  possess  a  thin  membrane  and  to  be 
relatively  poor  in  chromatin.  This  chromatin  is  dis- 
tributed as  a  thin  peripheral  layer  or  as  scattered  granules 
about  the  inner  surface  of  the  nuclear  membrane,  with  a 
few  granules  scattered  in  the  network  of  the  nonrefrac- 
tive,  nonstainable  nucleoplasm  (Fig.  7 — 5).  This  t^^pe 
of  nucleus  is  characteristic  of  histolytica  found  in  stools 
in  acute  dysentery  that  consist  exclusively  of  mucus  and 
blood.  In  stools  of  chronic  cases  of  dysentery  that  con- 
sist of  more  or  less  mucus  and  blood  mixed  with  fecal 
matter,  the  so-called  te.tragena  type  of  nucleus  is  com- 
monly met  with.  This  type  of  nuclear  structure  con- 
tains more  chromatin  than  the  preceding  type,  and  the 
chromatin  has  a  characteristic  arrangement.  It  is  dis- 
tributed partly  as  a  more  or  less  extensive  but  loose  layer, 
which  frequently  shows  radial  projections,  about  the  in- 
ner surface  of  the  nuclear  membrane,  and  partly  as  a  loose 
central  karyosome  of  varying  structure.  This  karyosome 
consists  tj^pically  of  a  central  granule,  the  'centriol,' 
surrounded  by  a  clear  halo  that  is  bounded  by  a  layer 
of  chromatin  granules  (Fig.  7 — 6).  All  intermediate 
stages  between  the  typical  histolytica  and  the  'tetra- 
gena'  types  of  nuclei  are  to  be  observed  in  dysenteric 


54  TROPICAL    SURGERY    AXD    DISEASES 

stools.  On  the  other  hand,  the  nncleus  of  Entameba  coli 
is  distinctly  visible  in  the  living  and  motile  entameba 
as  a  heavy  refractive  ring.  It  consists  of  a  nuclear  mem- 
brane and  a  relatively  large  amount  of  chromatin  which 
is  arranged  as  a  heavy,  dense,  continuous  or  broken  la^'er 
about  the  inner  surface  of  the  nuclear  membrane  and 
sometimes  also  in  a  small,  central,  dense  karyosome.  The 
interior  of  the  nucleus  consists  of  a  nonrefractive,  non- 
stainable  nucleoplasm  (Fig.  7 — 5).  Therefore,  the  nu- 
cleus of  Entameba  histolytica  differs  from  that  of  En- 
tameba coli  in  being  less  distinct,  often  invisible,  in  the 
living  entameba,  and  in  being  poorer  in  chromatin.  The 
'tetragena'  type  of  Entameba  histolytica  found  in  stools 
of  chronic  cases  of  dysentery  has  a  nucleus  more  closely 
resembling  that  of  Entameba  coli;  but  the  peripheral 
layer  of  chromatin  is  less  dense,  often  shows  radial  pro- 
jections, and  the  karyosome  is  loose  instead  of  dense  in 
structure. 

2.  In  Diarrheal  Stools 

''In  diarrheal  stools  and  stools  after  a  jDurgative,  En- 
tameba histolj^tica  is  usually  small,  sluggishly  motile,  or 
immotile,  and  possesses  a  nucleus  that  is  distinctly  vis- 
ible in  the  living  entameba  as  a  more  or  less  heavy 
periplieral  ring  of  chromatin  (Fig.  7 — 7).  Therefore,  it 
more  or  less  closely  resembles  Entameba  coli.  These 
forms  appear  to  represent  changes  in  Entameba  histolyt- 
ica preparatory  to  encystment.  They  are  spoken  of  by 
Darling  (1913)  as  the  'small  generation'  of  Entameba 
histolytica,  and  were  mistaken  by  Elmassian  (1909)  for 
distinct  species  of  entameba.  Although  the  small  size 
in  part  may  be  due  to  less  volume,  it  is  probable  that  it 
results  in  part  from  the  contraction  and  rounding  up  of 
the  much  extended  motile  entameba.  The  increase  of 
chromatin  content  of  the  nucleus  may  be  considered  a 
preparation  for  the  multiple  nuclear  division  that  is  to 


THE   COLOiT  55 

take  place  in  the  cyst.  AVliile  all  stages  from  the  typical 
histolytica  through  the  'tetragena'  to  this  preencysted 
stage  of  Eiitameba  histolytica  may  be  found  in  diarrheal 
stools  or  stools  after  a  purgative,  the  predominance  of 
the  preencysted  stage  and  the  more  or  less  resemblance 
of  it  to  Entameba  coli  make  the  differentiation  of  the 
two  species  difficult  and  sometimes  impossible  in  such 
stools. 

3.  Ix  FoE^EED  Stools 

"In  formed  stools  both  Entameba  histolj^tica  and  En- 
tameba coli  are  present  in  the  encysted  stage,'  and  it  is 
this  stage  of  the  entameba  that  presents  the  most  dis- 
tinctive character  for  making  a  differential  diagnosis. 
Furthermore,  the  identification  of  Entameba  histolytica 
in  the  encysted  stage  in  formed  stools  is  extremely  im- 
portant for  the  diagnosis  of  chronic  and  latent  infections 
and  for  the  control  of  treatment  of  entamebic  dysentery, 
and  constitutes  one  of  the  most  efficient  factors  in  the 
prophylaxis  of  this  disease. 

"The  cysts  of  Entameba  histolytica  (Fig.  9 — 8)  are 
relatively  small,  from  10  to  15  microns  in  diameter.  They 
are  round,  or  occasionally  oval,  moderately  refractive 
and  have  a  thin  cyst  wall.  The  completel}^  encysted  en- 
tameba contains  4  ring-form  nuclei  and,  usually,  one  or 
more  elongated  refractive  bodies,  that  stain  with  chro- 
matin stains  and  which  have  been  designated  by  Hart- 
mann  as  chromidial  bodies.  On  the  other  hand,  the  cysts 
of  Entameba  coli  (Fig  7 — 4)  are  larger  (from  15  to  20 
microns  in  diameter),  more  refractive,  and  usually  pos- 
sess a  thicker  cyst  wall.  The  completely  encysted  enta- 
meba contains  8  (occasionally  more)  nuclei  and  does  not 
include  'chromidial  bodies.'  The  encystment  of  Enta- 
meba coli  appears  to  proceed  more  rapidly  than  that  of 
Entameba  histolytica,  so  that  from  two  to  six  nuclear 
stages  are  infrequently  met  with.    In  the  case  of  Enta- 


56  TEOPICAL    SUEGEEY   AjSTD    DISEASES 

meba  histolytica,  nuclear  multiplication  appears  to  take 
place  early,  so  that  from  two  to  four  nuclear  stages  are 
frequently  seen  before  encystment  is  complete,  indeed,  oc- 
casionally in  the  motile  entameba. 

''For  convenience  of  reference,  the  more  distinctive 
and  constant  characters  of  Entameba  histolytica  and 
Entameba  coli  are  tabulated. 

Motile  Stage 
A.  Entamela  histolytica  B.   Entameia   coli 

1.  Appearance  hyaliue.  1.  Appearance  porcelaneous. 

2.  Kefractiveness  more   feeble.  2.  Ref ractiveness  more  pronounced. 

3.  Movements   active   in   the   fresh  3.  Movements  sluggish. 

stools.  J:.  Nucleus   distinct. 

4.  Chromatin  of  nucleus  scanty.  5.  Chromatin  of  nucleus  abundant. 

Encysted  Stage 
A.  Entamela  histolytica  B.   Entameba    coli 

1.  Cyst  smaller.  1.  Cyst  larger. 

2.  Cyst  less  refractive.  2.  Cyst  more  refractive. 

3.  Cyst  usually  contains  elongated  3.  Cysts    do    not    contain    ''chro- 

refractive  bodies   known  as  midial  bodies." 

''chromidial  bodies."  4.  Nuclei  8,  occasionally  more. 

4.  Nuclei  never  more  than  4.  5.  Cyst  wall  thicker. 

5.  Cyst  wall  thinner. 

' '  Therefore,  in  dysenteric  stools  and  sometimes  in  diar- 
rheal stools,  the  characters  of  the  motile  Entameba  his- 
tolytica are  fairly  distinctive,  and  the  experienced  ob- 
server will  have  little  difficulty  in  identifying  the  species. 
Unusually,  however,  in  diarrheal  stools  and  in  stools  after 
a  purgative,  Entameba  histolytica  is  in  a  preencysted 
stage  in  which  it  closely  resembles  Entameba  coli,  espe- 
cially in  its  sluggish  motility  and  its  distinct  nucleus  con- 
taining much  chromatin.  It  is  for  this  reason  that 
I  have  insisted  upon  stool  examinations  without  the  ad- 
ministration of  a  purgative.  In  the  case  of  natural  diar- 
rheal stools,  diagnosis  can  usually  be  made  by  an  experi- 
enced protozoologist  by  a  careful  study  of  the  stools  on 
successive  days;  but  it  is  always  advisable  to  endeavor  to 


TME    COLON  57 

obtain  a  fonned  stool.  Formed  stools,  when  they  can  he 
obtained,  are  always  to  be  preferred  for  making  a  labora- 
tory diagnosis  of  entamebic  infection,  because  the  en- 
cysted entamebcie  in  such  stools  present  the  most  distinc- 
tive morphologic  characters  for  the  differential  diagnosis 
between  Entameba  histolytica  and  Entameba  coli. 
Finally,  it  is  to  be  insisted  upon  that  a  negative  diagnosis 
should  never  be  made  on  a  single  stool  examination,  since 
the  entamebffi  may  occasionally  be  absent  from  the  stools 
of  an  infected  person;  nor  upon  the  identification  of  En- 
tameba coli  in  a  stool,  since  there  may  exist  a  double 
parasitization  with  this  species  and  Entameba  histolytica. 
In  all  such  cases  a  diagnosis  should  be  based  on  several 
examinations  made  on  different  days." 

The  following  matter  is  quoted  from  an  article  by 
A.  W.  Sellards  and  W.  A.  Baetjer  :* 

"In  the  diagnosis  of  amebic  dysentery,  it  is  ordina- 
rily considered  essential  that  the  presence  of  E.  his- 
tolytica be  demonstrated  in  association  with  definite 
clinical  symptoms.  In  three  cases  of  obscure  diarrhea 
it  Avas  found  that  ameb<e  were  present  in  the  intestine, 
which  could  not  be  identified  morphologically  with  either 
E.  histolytica  or  B.  coli.  Animal  inoculation  proved  that 
these  amebse  were  definitely  pathogenic,  the  symptoms 
which  characterized  the  disease  in  the  patient  appearing 
in  the  animals.  After  a  careful  consideration  of  the 
various  factors  involved  in  these  cases,  we  feel  that  it 
is  necessary  to  diagnose  amebic  dysentery  (intestinal 
amebiasis)  under  conditions  in  ^^■hich  the  clinical  symp- 
toms are  distinctly  atypical  and  the  ameb?e  present  vary 
markedly  in  their  morphology  from  E.  histolytica.  In- 
deed, amebic  dysentery  must  sometimes  be  diagnosed  in 
the   absence   of  trophozoites   and  when  only  two-   and 


*The   Recognition  of  Alvpical   Forins  of  Intestinal   AnKcbiasis,   Bull,    [ohns   Hopkins 
Hosp.,   February,   1915,  xxvi,   No.   288. 


58  TROPICAL    SURGERY    AND    DISEASES 

three-nucleated  cysts  are  present.  A  diagnosis  niider 
such  conditions  should  he  confirmed  hy  the  inoculation 
of  animals. 

''As  regards  the  systematic  position  of  these  strains, 
and  their  relation  to  histolytica,  definite  evidence  was 
ol^tained  that  the  amount  of  chromatin  which  character- 
izes the  nucleus  of  E.  histolytica  may  undergo  fairly 
marked  variation.  Also  the  number  of  nuclei  in  the 
propagative  stage  has  always  been  considered  as  being 
sufficiently  constant  to  furnish  a  satisfactory  basis  for 
the  differentiation  of  species.  In  these  strains  marked 
variation  occurred  in  the  number  of  nuclei  in  the  c^^sts, 
sometimes  only  two  and  three  being  found,  and  under 
other  conditions  four  and  often  five  or  six  nuclei.  Con- 
sequently we  prefer  to  regard  the  strains  of  ameba^  oc- 
curring in  these  cases,  not  as  a  new  variety,  but  as  an 
atypical  histolytica  temporarily  modified  by  environ- 
ment. 

"For  the  present  it  seems  permissible  to  recognize 
only  two  entamebss  of  man,  namely  E.  histolytica  and 
E.  coli.  We  do  not  feel  that  E.  polecki  (v.  Prowazek, 
1912),  found  sometimes  in  man,  or  E.  testudinis  (Hart- 
mann,  1910)  of  certain  animals  can  be  accepted  as  dis- 
tinct species,  in  view  of  the  limited  information  con- 
cerning the  characteristics  of  the  vegetative  stage  under 
changing  conditions  of  environment,  the  absence  of  sxDe- 
cific  tests  for  pathogenesis  in  a  susceptible  host  and  the 
absence  of  information  concerning  the  propagative 
stage. ' ' 

Treatmeistt 

In  writing  on  this  subject  in  1911,  in  describing  the 
curiosities  of  the  statistics,  I  made  the  slighting  state- 
ment, ' '  that  according  to  some  authors,  there  is  no  reason 
for  dysentery  existing  in  the  same  world  with  ipecac," 
and  it  has  since  come  to  pass  that  treatment  by  emetin. 


THE    COLON  50 

an  inspiration  of  Rogers,"  is  tlio  greatest  cliemotliei-a- 
peutic  triumph  of  recent  times.  It  apparently  cures, 
with  a  magical  celerity,  amebic  dysenteries  in  any  except 
a  dying  stage.  One-half  grain  of  the  hydrochloride  of 
emetin  hypodermically,  as  an  initial  dose,  and  one-third 
of  a  grain  three  times  a  day  for  about  ten  days,  as  recom- 
mended by  Vedder,*  is  folloAved  by  no  unpleasant  effects, 
sucli  as  occur  from  large  dosages  which  run  as  high  as 
four  to  five  grains  a  day.  When  the  patient  seems  cured, 
the  treatment  should  be  suspended  and  the  stools,  begin- 
ning fifteen  days  after,  watched  for  several  months,  for 
Entamelui  histolytica,  especially  in  the  resting  or  en- 
cysted stages.  Any  recurrence  of  symptoms  demands  a 
second  course  of  treatment,  when  larger  doses  may  be 
emplo^^ed.  Walker's  experiments  prove  that  the  emetin 
treatment  does  not  kill  all  of  the  entameba?  in  the  lumen 
of  the  intestine  and  these  cases  become  chronic  car- 
riers and  a  menace  to  their  neighbors,  as  he  asserts  that 
dysentery  is  propagated  almost  solely  by  these  carriers 
who  are  constantly  passing  in  their  stools,  often  in  enor- 
mous numbers,  the  resistant  encysted  stage  of  Entameba 
histolytica.  The  treatment  of  these  carriers  is  of  the 
utmost  importance.  Emetin  used  by  colonic  irrigations 
has  given  very  bad  results.  It  is  possible  that  the  amebas 
may  be  removed  from  these  carriers  by  a  course  of  qui- 
nine, 1:1000,  or  of  silver  nitrate,  1:1000,  irrigations. 

In  addition  to  emetin  hypodermically,  some  are  now 
using  freshly  made  salol-coated  ipecac  pills,  and  begin 
with  a  huge  dose,  usually  about  eighty  grains  a  day  in 
four  doses  of  twenty  grains  each.  The  patient  is  kept 
quiet,  on  a  light  diet,  and  the  dose  is  reduced  about  ten 
grains  a  day;  every  four  or  five  days  the  ipecac  is  stopped 
and  a  good  saline  cathartic  is  given.     The  dose  is  run 


•■'Rogers,  Leonard,  I.  M.  S. :  The  Rapid  Cure  of  Amebic  Dysenterj'  and  Hepatitis 
by  Hypodermic  Injections  of  Soluble  Salts  of  Emetine,  Brit.  Med.  Jour.,  June  22,  and 
Aug.   24,  1912. 

■•X'edder,  Edward  P..:  Origin  and  Present  Status  of  the  Emetine  Treatment  of 
Amebic  Dysentery,  Jour.  Am.  Med.  Assn.,  February  14,  1914. 


60  TROPICAL    SUEGEFiY   AlsD   DISEASES 

down  until  tlie  patient  is  getting  about  ten  grains  a  day. 
This,  tliey  claim,  is  usually  effective  in  ridding  the  stools 
of  all  entamebse,  as  the  ipecac,  internally  administered, 
mixes  with  the  feces  and  comes  in  direct  contact  with  the 
encysted  parasites. 

The  last  word  on  this  subject  will  not  be  written  until 
a  further  study  of  the  effect  of  ipecac  and  emetin  has 
been  made,  so  that  they  can  be  emplo3^ed  to  destroy  all 
of  the  entamebcP  in  the  patient,  especially  in  the  stools 
of  carriers. 

Since  the  discovery  of  emetin  only  grossly  neglected 
cases  in  which  the  colon  has  suffered  severe  structural 
damage  ma^^  require  irrigations  through  an  appendi- 
costomy  or  better  a  cecostomy;  although  emetin  has  de- 
stroyed all  of  the  Entamebffi  histolytica  in  the  bowel  wall 
in  such,  cases,  they  die  from  sepsis;  in  some  of  these 
patients  a  cecostomy  under  local  anesthesia  may  be  in- 
dicated. Most  of  the  recent  work  (1916)  on  amebiasis 
has  been  concerned  with  the  medical  treatment  of  car- 
riers ill  which  the  subcutaneous  injection  of  emetin 
hydrochloride  fails. 

The  greatly  increased  use  of  emetin  recently,  especially 
by  quacks,  and  the  appearance  in  the  market  of  an  impure 
product  lias  put  the  profession  on  its  guard  against 
poisoning  and  even  death  from  this  drug  although  ad- 
ministered in  small  amounts.  One  fatal  case  at  the  Joliiis 
Hopkins  Clinic  received  one  and  one-half  grains  for 
twenty  days;  the  symptoms  were  diarrhea,  acute  renal 
iiisufticiency,  acidosis,  blood  in  the  urine,  and  broncho- 
pneumonia; the  patient  died  thirty  days  after  the  first 
injection  and  ten  days  after  the  last.  It  must  always  be 
remembered  that  the  products  supplied  as  emetin  hydro- 
chloride are  variable  in  comjjosition  and  in  toxicity  to  a 
degree  which  constitutes  a  serious  danger.  Physicians 
should  insist  on  some  declaration  from  the  firm  supply- 
ing the  drug  as  to  its  purity  and  as  to  the  standard  em- 
ployed.    (Jour.  Am.  Med.  Assn.) 


THE  colo:n'  61 

Treatment  of  Carriers  with  Oil  of  Chenopodium.^ — 
Fourteen  carriers,  all  men,  were  treated  by  Walker  and 
Emricli  with  oil  of  chenopodium  at  the  Candelaria  Hos- 
pital of  the  Madeira-Marmore  Railroad  Co.,  Porto  Velho, 
Amazonas,  Brazil;  ten  Avere  cured  and  four  remained  ap- 
parently uncured;  they  believed  that  the  latter  might 
have  been  cured  had  they  received  satisfactory  prelim- 
inary purgation.  In  the  ten  cured  cases,  six  resulted  from 
a  single  treatment ;  one  after  a  double  treatment  with  one 
day's  interval  between,  and  three  after  three  treatments 
following  two  relapses.  The  technic  found  most  effective 
consisted  of  (1)  magesium  sulphate,  14  to  1  ounce,  at  6 
A.M.;  (2)  oil  of  chenopodium,  16  minims,  in  gelatine 
capsules  at  8  a.  m.,  10  a.  m.,  and  12  m.,  and  (3)  castor  oil, 
1  ounce,  containing  chloroform,  50  minims,  at  2  p.  m. 
This  dosage  is  for  adults.  The  preliminary  purgation  is 
most  important;  its  purpose  is  twofold,  first  to  remove 
the  excess  of  fecal  matter,  and,  second,  to  bring  the  en- 
tamebas  out  of  their  protective  cysts  and  subject  them  in 
the  vegetative  condition  to  the  action  of  the  chenopodium. 
It  was  found  that  this  XDreliminary  purging  must  abso- 
lutely secure  free  fluid  bowel  movements  before  the  cheno- 
jDodium  is  given  and  that  the  chenopodium  must  be  ad- 
ministered while  the  stools  are  fluid.  Finally,  the  stools 
must  be  examined  repeatedly  after  the  treatment  by  one 
capable  of  identifying  Entameba  histolytica  in  the  rest- 
ing, encysted,  and  motile  stages.  At  least  three  examina- 
tions on  different  days  are  advisable;  when  possible,  ex- 
aminations should  be  made  at  intervals  for  some  Aveeks 
or  months  in  order  to  be  sure  of  a  cure. 

PPiOPHYLAXIS 

According  to  Walker's  exj)eriments,  the  knowledge 
of  the  part  which  these  carriers  of  Entameba  histoly- 


^Walkcr  and   Hmiich:     Jour.   Am.   Aled.  Assr..,  ^[ay   19,   1917,  l.xviii,   1456. 


62  TROPICAL    SURGERY    AND    DISEASES 

tica  probably  play  in  the  spread  of  entamebic  dysentery, 
together  with  the  ease  and  certainty  with  which  such 
carriers  can  be  detected  by  microscopic  examination 
of  their  stools,  makes  the  prophylaxis  of  this  disease 
relatively  simple.  It  is  believed  that  it  would  be  pos- 
sible, were  it  practicable,  to  eradicate  this  disease  from 
any  region  by  a  systematic  examination  of  stools  and  the 
treatment  or  isolation  of  all  persons  found  to  be  carriers 
of  Entameba  histolytica.  In  the  absence  of  such  thorough- 
going prophylactic  measures,  a  sanitar}^  disposal  of  all 
fecal  matter  should  be  insisted  upon  and  household  car- 
riers of  Entameba  histolytica  should  be  eliminated. 
Native  household  servants  who  cook  and  handle  food, 
who  are  usually  more  or  less  uncleanly  in  their  habits, 
and  some  of  whom  are  carriers  of  Entameba  histolytica, 
are  believed  to  be  one  of  the  chief  sources  of  infection  of 
white  persons  residing  in  the  Tropics;  and,  as  a  most 
essential  prophjdactic  measure,  stool  examinations  should 
be  made  of  all  such  servants  and  those  found  infected 
should  be  discharged  or  subjected  to  treatment. 

Equally  important  is  the  matter  of  personal  prophy- 
laxis. On  account  of  the  relatively  long  incubation  period 
of  the  disease  and  the  frequent  occurrence  of  chronic  and 
latent  infections,  it  will  usually  be  possible  to  anticipate 
with  treatment  an  attack  of  dysentery.  If  persons  resid- 
ing in  endemic  regions  would  have  frequent  stool  exam- 
inations made  by  a  competent  protozoologist,  and,  if  at 
any  time  parasitization  with  Entameba  histolytica  hav- 
ing been  discovered,  would  undergo  treatment,  it  is  be- 
lieved that  it  would  rarely  be  necessary  for  a  person  to 
suffer  from  entamebic  dysentery.  A  stool  examination 
made  once  a  month  A\'ould  ordinarily  be  sufficient  to  an- 
ticipate an  attack.  Sucli  a  procedure  would  constitute 
a  most  efficient  method  of  personal  prophylaxis. 


THE    COLON 


63 


Balantidial  Dysentery 

The  first  case  was  reported  in  1857  in  Sweden.  In 
1904,  125  cases  were  collected  from  every  country  and 
since  then  12  cases  have  been  published.  In  the  Philip- 
pines this  infection  is  not  uncommon  and  it  is  probable 
that  parasitization  with  Balantidium  coli  is  frequently 
overlooked  on  account  of  the  few  clinical  symptoms  and 


Fig.    8. — Colon   of   man   dead    from   Balantidium    coli   infection.      (I'owman.) 

the  infrequent  appearance  of  the  parasite  in  the  stools 
of  infected  persons. 

Clinically,  it  is  recognized  by  the  parasite  in  the  stools; 
some  of  the  cases  show  a  diarrhea  or  dysentery.  The 
parasites  may  be  absent  for  weeks  and  when  found  are 
usually  in  small  numbers,  as  many  of  the  infections  are 
latent.  The  mortality  is  not  known.  The  postmortem 
pathologic  changes  show  atypical  blackish  ulcerations  of 


64 


TROPICAL    SURGERY    AND    DISEASES 


the  colon  (Fig.  8).  The  Balantidia  were  found  in  the 
wall  of  the  gut,  the  regional  h^nph  nodes  and  in  blood  ves- 
sels and  lymph  spaces,  singly  or  in  groups  (Figs.  9,  10, 
and  11).  Liver  abscess  has  not  heen  observed.  Monkeys 
and  pigs  are  naturally  infected.  An  examination  of  pigs 
in  the  Philipijines  convinced  Walker'''  that  a  large  jn'opor- 


Fig.  9. — Section  of  large  intestine  of  monkey,  showing  three  Balantidium  coli  suis 
in  the  deeper  part  of  the  mucosa.  (Walker:  Experimental  Balantidiasis,  Philippine 
Journal   of   Science,  \'III,   B,   No.    S.) 


tion  of  them  are  parasitized  with  the  encysted  jDrotozoon, 
but  it  does  not  produce  symptoms  or  lesions  in  its  host, 
although  they  are  morphologically  identical  with  those 
in  man. 


''Walker,    K.    L. :      Experimental    Balantidiasis,    Philippine   Jour.    Sc.,    October,    1913, 
Sec   B,  viii,  No.  5. 


THE    COLOX  60 


Treatment 


Walker^  determined  quantitatively  tliat  tlie  comioomids 
of  arsenic  and  antimony,  the  aniline  dj^es,  ipecac  and  eme- 
tin,  and  qninine,  possess  little  or  no  halantieidal  action, 
but  the  salts  of  the  heavy  metals,  especiall.v  mercury  and 
silver,  were  eminently  balanticidal;  that  it  is  possible 


-♦* 


•     •  •  •      *   •  •>  ^ 


v'- 


Fig.  10. — Section  of  a  mesenteric  lymph  gland  of  monkey,  showing  several  Balan- 
tidium  coli  hominis  in  the  edge  of  the  glandular  tissue.  (Walker:  Experimental 
Balantidiasis,   Philippine  Journal   of   Science,   \'III,  B,   No.   5.) 

that  some  of  the  inorganic  salts  of  mercury  or  silver, 
given  by  mouth  or  hypodermically,  might  be  efficient,  as 
they  are  eliminated  in  part  by  the  mucosa  of  the  large 
intestine,  but  the  local  treatment  is  impracticable  because 
they   are   precipitated   by   albumin   and   are    relatively 


"Walker,  E.  L. :  Quantitative  Determination  of  the  Balanticidal  Activity  of  Certain 
Drugs  and  Chemicals  as  a  Basis  for  Treatment  of  Infections  with  Balantidium  Coli, 
Philippine  Jour.   Sc,   1914. 


66 


TROPICAL    SURGERY    AXD    DISEASES 


toxic  to  man.  The  practical  value  of  the  organic  com- 
pounds of  silver  which  possess  considerable  balanticidal 
activity  can  be  determined  only  by  clinical  experience. 

Bacillary  Dysentery 

Bacillary  dysentery,  caused  by  groups  of  closely  re- 
lated bacilli,  is  sporadic  and  prone  to  become  epidemic. 


Fig.   11. — Section  of  the  large  intestine  of  a  man  dead  from  Balantidial  dysentery- 
(Walker:     Experimental  Balantidiasis,  Philippine  Journal  of  Science,   VIII,  B,   No.   5.) 

The  accepted  etiologic  organisms  are  the  Shiga  bacillus 
and  the  Flexner  bacillus  associated  with  the  Bacillus 
coli,  which  occur  throughout  the  intestine  but  principally 
in  the  lower  bowel.  The  onset  may  be  sudden,  although 
a  premonitory  period  of  gastrointestinal  disturbance  of 
one  or  two  days  is  not  uncommon;  this  is  characterized 
by  griping,  tenesmus,  fever,  and  diarrhea  until  blood  and 


THE    COLOX  67 

mucus  form  the  entire  discharges  with  a  continued  desire 
to  defecate.  The  most  severe  cases  have  resulted  fatally, 
within  four  days,  from  gangrene  of  the  colon ;  mild  forms 
often  recover  on  the  third  or  fourth  day  while  still  in  the 
mucous  stage.  The  surgical  complications  are  few  com- 
pared with  entamebic  dysentery.  Allbutt  and  Eolleston 
mention  arthritis  of  the  large  joints  as  a  rather  frequent 
sequel;  general  sepsis  and  even  pyemia,  with  parotitis, 
diffuse  abscess  or  peritonitis  are  also  occasionally  met 
with.  Tlie  liver  in  the  majorit}^  of  severe  cases  shows 
more  or  less  evidence  of  hepatitis  with  congestion,  but 
abscess  formation  is  very  rare.  Paralysis  of  the  loAver 
extremities,  of  the  sphincter  ani  or  of  the  bladder,  hemor- 
rhoids, prolapsus  ani,  cystitis,  nephritis,  and  especially 
gastroduodeno-hepaticoi3ancreatic  disorders  are  most 
common. 

Under  treatment  by  drugs  the  disease  has  a  mortality 
of  ten  to  thirty  per  cent.  The  antitoxic  serum  prepared 
by  Shiga  from  the  bacillus  strain  bearing  his  name  is  fol- 
lowed by  remarkable  results  and  a  mortality  of  less  than 
one  per  cent  in  cases  infected  by  the  bacillus;  no  serum 
against  the  Flexner  bacillus  or  other  acid  strains  seems 
to  be  effective  as  at  present  prepared.  Vaccine  treatment 
has  not  been  successful. 

A  description  of  other  surgical  diseases  of  the  colon 
such  as  tuberculosis,  carcinoma,  dilatation,  prolapse  and 
infections,  secondary  to  general  diseases,  would  not  differ 
materially  from  these  conditions  encountered  elsewhere. 

General  Intestinal  Parasitism 

At  least  seven  different  parasites  influence  surgical 
prognosis  and  give  rise  to  dysenteric  symptoms;  amebic, 
malarial,  balantidial,  kala-azar  (not  yet  found  in  the 
Philippine  Islands),  schistosomal,  bacillary  and  esoph- 
agostomal  (not  yet  found  in  man  in  the  Pliilippine 
Islands). 


bo  TROPICAL    SUEGEEY    AXD    DISEASES 

Many  forms  of  verminous  disturbance  of  the  intestinal 
function  remain  to  be  described.  Statistical  studies  of 
the  evidence  of  intestinal  worms  among  Filipinos,  al- 
though so  far  based  mostly  on  but  one  coverslip  prepara- 
tion with  no  preliminary  catharsis,  nevertheless  show  that 
such  intestinal  parasites  as  ascaris,  trichuris,  hookworm, 
ox^niris,  tenia,  hymenleiDsis,  and  strongyloides  are  so  com- 
mon that  at  least  one  hundred  per  cent  of  Filipinos  har- 
bor one  or  more  species  of  these  intestinal  worms;  there 
are  very  few  single  infections  per  one  hundred  persons 
and  1.85  infections  per  person  seems  to  be  a  fair  estimate 
of  intestinal  helminthiasis  among  Filipinos.  These  esti- 
mates are  based  on  the  examinations  of  19,302  natives 
from  every  part  of  the  Islands.  To  this  may  be  added 
the  examinations  of  the  stools  of  over  6,000  Filipinos  in 
St.  Paul's  Hospital,  Manila,  from  1905  to  1910,  which 
showed  about  1.50  infections  per  person. 

Lartigau  has  shown  that  bowel  parasites  and  their 
products  and  bowel  bacteria  are  carried  to  the  liver  b}^ 
the  portal  system  and  that  on  their  way  back  to  the 
l30wel  they  not  only  excite  disturbance  of  heioatic  struc- 
ture and  function,  but  cause  various  infections  of  the 
bile  tract  and  mucosa;  the  gut  again  suffers  by  receiving 
the  secretion  of  a  damaged  liver  and  a  pathologic  vicious 
circle  is  established.  They  also  cause  profound  reflex 
disturbance  of  function  in  the  gastroduodeno-hepatico- 
pancreatic  physiologic  system  secondarily,  by  acting  as 
irritants  in  the  large  bowel,  just  as  a  chronic  appendix 
reflexly  causes  gastric  and  duodenal  disturbances,  which 
in  turn  interfere  with  the  mechanism  of  secretion,  storage, 
and  outflow  of  digestive  secretions  and  of  bile,  thereby 
producing  conditions  favorable  both  for  bacterial  infec- 
tion in  the  gall  bladder  and  for  systemic  infections.  The 
importance  to  the  surgical  patient  of  correcting  these 
intestinal  conditions  is  very  great:  for  instance,  nearly 
fifteen  per  cent  of  Philippine  typhoids  have  hemorrhages. 


THE    LIVER  69 

THE  LIVER 

Entamebic  Abscess 

It  is  merely  another  tribute  to  the  marvelous  ability 
of  the  liver  to  dispose  of  the  poisons  and  pathogenic  or- 
ganisms which  pass  in  contact  with  its  cells,  that  abscess, 
secondary  to  a  colon  parasitized  with  entamebte,  is  not 
more  frequent;  because  the  parasites  are  usually  to  be 
found  in  the  portal  vessels  together  with  the  daily  output 
of  other  septic  and  toxic  substances  from  the  diseased  gut. 
Interpretation  of  clinical  signs  and  symptoms  and  the 
treatment  of  liver  infections  demand  consideration  of  the 
following:  the  extensive  relationship  of  the  organ  to 
other  derivatives  of  the  i:)rimitive  gut;  its  wonderful 
function;  its  fixed,  for  clinical  purposes,  position:  its 
great  friability;  its  great  vascularity,  especially  during 
the  portal  obstruction  and  back  pressure  of  an.  acute 
hepatitis ;  that  its  veins  have  no  valves  and  lack  contract- 
ible  tissue ;  that  it  has  two  vascular  systems,  the  main 
trunks  of  each  in  one  pedicle,  which  can  be  completely 
controlled  by  digital  or  f orci-pressure ;  and  finally  the 
clinical  importance  of  the  accessory  portal  systems  and 
the  variations  in  their  blood  pressure. 

Diagnosis  ai^b  Treatmeis^t  of  Liver  Abscess 

When  the  colonic  infection  is  chronic,  there  often  oc- 
curs an  acute  parenchymatous,  cloudy  swelling  of  the 
liver  in  which  an  ameba-laden  embolus  from  a  septic 
thrombophlebitis  of  the  ulcerated  colon  finds  both  lodg- 
ment and  the  conditions  favorable  for  developing  an  ab- 
scess. Enlargement  of  the  liver  and  an  exacerbation  of 
the  dysentery,  rise  of  temperature,  marked  leukocytosis, 
sweating,  pain  between  the  ribs  on  pressure  and  in 
the  shoulder,  make  the  diagnosis  easy;  but  some  solitary 
abscesses  are  practically  without  symptoms  until  they 
become  large  and  cause  marked  pain  from  tension,  or 


70 


TROPICAL    SUEGEEY    AXD    DISEASES 


until  a  dry  grmiting  cough  indicates  threatened  perfora- 
tion into  the  king.  Exploratory  puncture  is  dangerous, 
unless  one  is  prejDared  to  follow  up  a  discovery  of  pus 
l)y  immediate  operation  before  withdrawing  the  needle. 


Fig.   i: 


-L,iver.     Upper  surface   shov/ing  minute   multiple   foci   of  secondary   infection 
from    entamebiasis    of    the    colon.       (Author's    collection.) 


Fluctuation  can  of  course  never  be  detected.  When 
the  diagnosis  is  difficult  and  the  patient's  condition  is 
fair,  one  can  often  safely  follow  an  expectant  plan  for  a 


fortnight  or  longer. 


Fig.   13. — Liver.     Cut  surface  of  same  specimen  as  Fig.    12.      (Author's  collection.) 

The  proi^er  way  to  examine  a  liver  for  pus  is  to  expose 
sufficient  of  its  surface  to  allow  of  thorough  and  re- 
peated hollow  needle  exploration  from  day  to  day;  this 
is  readily  provided  for  by  jDacking  a  wound  widely  open 
until  adhesions  have  formed  about  an  opening  that  is 


THE    LIYEPv 


71 


floored  l)y  the  liver,  preferably  on  the  outer  surface  of  the 
right  lobe.  As  emetin  liypodermically  will  search  out 
and  destroy  entaniebse  Avherever  they  may  be  in  the  living 
tissues,  entaniebie  liver  abscess,  unless  a  mixed  infection, 
is  now  very  soon  arrested,  rendered  sterile  as  to  para- 
sites, and  needs  drainage  for  a  short  time  only  to  effect  a 
cure  of  the  large  solitary  variety. 


Fig.   14. — Liver.      Section  of  right  lobe  \vi;h  large  multiple  abscesses,  showing  beginning 
coalescence   of   three   central   abscesses.      (Author's   collection.) 


It  is  possible  that  the  hitherto  hopeless  form  of  mul- 
tiple, minute  abscesses  (Figs.  12  and  13),  sprinkled 
throughout  the  entire  liver  substance,  or  even  the  larger 
kind  (Fig.  1-1)  will  become  arrested,  and  in  time  absorljed 
by  natural  processes  after  emetin  has  killed  off  the  patho- 
genic parasites.  In  an  experience  of  over  one  hundred 
cases  of  liver  abscess  which  I  operated  upon  betAveen  1900 
and  1907,  ninety-five  per  cent  were  in  the  right  lobe  and 


72 


TROPICAL    SURGERY    AND    DISEASES 


Fig.   15. — lyiver.     Solitary  superficial  entamebic  abscess   on  outer  surface  of  right  lobe. 

(Author's    collection.) 


Fig.    16. — Curvilinear   incision   to    expose   9th   and    10th   ribs. 


of  the  so-called  single  variety  (Fig.  15) ;  ninety  per  cent 
of  these  recovered;  one  case  of  multiple  abscesses  in  which 
two  or  more  small  abscesses,  which  may  have  been  the 
only  ones,  were  reached  and  opened,  also  recovered.    Even 


THE    LIVEK 


16 


after  efficient  use  of  emetin  the  old  laAv,  uhi  pus  ibi  evacuo, 
will  always  prevail ;  the  method  of  attack  must  be  decided 
upon  according  to  the  location  of  the  pus.     British  sur- 


Fig.  17. — Resection  of  four  inches  of  lOth  rib;  resulting  gutter  to  be  closed  immediately 

by  catgut  suture. 


Fig.  18.— Cavity  or  gutter  left  by  rib  resection,  partly  sutured;  dotted  line  below 
indicates  the  next  incision  which  is  close  to  the  vipper  border  of  the  11th  rib  and 
extends  into  the  peritoneal  cavity  through  all  layers  of  chest  wall  and  diaphragm. 

geons  in  the  Tropics  are  partial  to  a  quick  and  easy 
method  by  aspiration  and  syphonage  and  the  instrument 
makers  sell  many  sets  of  special  instruments  for  this 


74 


TEOPICAL    SCRGERY    AXD    DISEASES 


purpose  devised  by  Mansoii  and  others.  Like  all  opera- 
tions in  which  the  operator  can  not  see  what  he  is  doing, 
it  has  few  terrors  for  the  most  timid.  Such  a  procedure 
is  unscientific  and  unsafe  but  has  its  uses  and  is  to  be 
commended  to  one  untrained  in  surgerj^  when  conditions 
are  such  that  a  surgeon  is  not  available. 

The  Abdominal  Route.^ — When  the  liver  dullness  ex- 


Fig.  19. — While  incision  into  the  peritoneal  cavity  is  being  made  the  mobilized 
chest  wall  is  held  firmly  against  the  diaphragm  by  two  fingers  of  an  assistant;  this 
should  prevent  entrance  of  air  into  the  pleural  cavity  until  the  cut  edges  of  chest  wall 
and  diaphragm  can  be  clamped  together  and  then  sutured,  making  air  tight  closure  of 
the  pleural  cavity. 

tends  well  below  the  costal  margins  and  especially  when 
the  organ  bulges  anteriorly  as  it  sometimes  does  in  neg- 
lected cases,  the  abdominal  route,  preferably  through  the 
right  rectus  muscle,  if  visceroparietal  adhesions  are  en- 
countered, amounts  to  nothing  more  than  a  simple  oncot- 


^McDill,  J.  R. :     Tropical  Infections  of  the  Derivatives  of  the  Primitive  Gut:   Their 
Complications  and  Treatment,   Surg.,  Gynec.  and  Obst.,  Nov.,   1911,  523-558. 


THE    LIVER 


75 


omy.  If  adliesioiis  are  limited  and  recent,  or  absent,  the 
abscess  cavity  if  accessible  should  l)e  opened  thvougii 
a  ring  of  gauze  packed  between  the  liver  and  the  abdom- 
inal wall,  either  immediately  or  after  forty-eight  hours, 
according  to  the  two-stage  principle.  A  transpleural 
operation  to  attack  a  liver  abscess,  before  it  has  developed 
to  an  extreme  stage  or  before  the  liver  swelling  is  evident 


Fig.  20. — For  demonstration  only;  the  edges  of  chest  wall  and  diaphragm,  which  are  to 
be    united    by    suture,    are    held    apart. 

on  inspection,  gives  the  best  access  to  the  entire  right 
lobe  in  which  ninety-five  per  cent  of  abscesses  are  found. 
This  exposure  of  the  liver  surface  is  not  affected,  except 
favorably,  by  the  great  reduction  in  size  that  occurs 
within  twenty-four  hours  after  needling  a  swollen  liver; 
if  pus  is  not  found  at  the  time  of  operation,  the  organ 
can  be  explored  through  the  wound  daily  for  weeks,  if 


76 


TEOPICAL    SUEGERY   A^D    DISEASES 


necessary,  with  tlie  hollow  needle,  nnder  cocaine  anes- 
thesia. 

The  following  procedure  avoids  pneumothorax  and 
empyema  and  has  been  quite  satisfactory:'  1.  Place  the 
patient  flat  on  the  back  or  Avith  the  right  shoulder  and 
hip  raised  a  little  with  the  right  arm  at  right  angles  to 
the  body.  2.  (Fig.  16)  Curvilinear  incision  to  expose 
ninth  and  tenth  ribs.  Reflect  in  one  flap  all  of  the  tissues 
down  to,  but  not  including,  the  fascia  overlying  the 
muscles.    3.  (Fig.  17)  Sub]3eriosteal  resection  of  10  cm.. 


Fig.    21. — Suture   of   chest  wall   and   diaphragm   completed,    showing   exposure    of   liver. 

(4  inches)  of  the  tenth  rib;  removal  of  the  ninth  rib  also 
is  sometimes  indicated;  great  care  is  necessary  to  avoid 
wounding  the  periosteal  bed  composed  of  periosteum,  en- 
dothoracic  fascia  and  parietal  pleura;  close  the  resulting 
gutter  inunediately  with  a  running  catgut  suture  through 
the  entire  thickness  of  the  musculature.  This  results  in 
a  loose  and  movable  section  of  the  chest  wall.  1.  (Fig.  18) 
Cavity  or  gutter  left  by  rib  resection  partially  sutured. 
The  dotted  line  below  indicates  the  next  incision  which 
follows  closely  the  upper  border  of  the  eleventh  rib;  it 
is  coextensive  with  the  rib  resection  and  extends  into 


THE    LTVEIl  77 

the  peritoneal  cavity  dividing  all  laj^ers  of  the  chest  wall 
and  the  diaphragm.  5.  (Fig.  19)  While  this  incision  is 
being  made,  the  fingers  of  an  assistant  firmly  press  the 
loosened  chest  wall  inwards  and  against  the  diaphragm  to 
prcAT'nt  pnenmothorax  when  the  incision  opens  or  crosses 
the  pleural  sac;  as  soon  as  the  pleural  cavity  has  been 
passed  and  the  thickness  of  the  diaphragm  divided,  the 
peritoneal  cavity  is  opened;  this  should  occur  first  about 
the  center  of  the  wound;  the  two  upper,  cut  margins  of 
mobilized  chest  wall  and  diaphragm,  respectively,   are 


"SR-iM^ill 


Fig.  22. — Mikulicz  pack  to  procure  adhesions,  after  failure  to  find  an  abscess; 
through  the  adhesions  daily  explorations,  with  cocaine,  can  be  made,  if  necessary,  until 
pus  is  found. 

tlien  clamped  together  with  two  or  three  forceps,  effectu- 
ally closing  the  pleural  cavit}^  The  oi^ening  can  now  be 
extended  right  and  left  by  first  securely  clamping  the  dia- 
phragm to  the  chest  wall,  and  when  a  running  catgut 
suture  replaces  the  forceps,  making  air-tight  closure  of 
tlie  pleural  cavity,  the  liver  is  freely  exposed  and  ready 
for  even  a  manual  exj)loration.  Fig.  20  demonstrates  the 
cut  edges  of  chest  Avail  and  diaphragm  held  apart;  be- 
tween the  flaps  the  pleural  cavity  is  shown;  below  is  the 
liver.     Fig.  21  shows  coaiDtation  by  suture  of  the  edges 


(^  TROPICAL    SURGEEY    AND    DISEASES 

of  chest  wall  and  diaphragm  completed,  shoAving  extent 
of  exposure  of  the  surface  of  the  right  lobe  of  the  liver. 
Fig.  22  shows  a  case  in  which  pus  is  not  found  at  the  time 
of  operation,  showing  gauze  packed  in  a  Mikulicz  hag 
which  extends  beneath  the  wound  margins  covering  an 
area  of  liver  surface  about  6.5  cm.  (2^2  inches)  in  diam- 
eter. 

After  adhesions  form,  the  liver  can  be  explored  daily 
if  necessary  under  local  cocaine  anesthesia.    In  one  case 


Fig.  23. — Drain  in  place,  gauze  ring  around  tube  to  prevent  soiling  of  peritoneum  and 

to   form  adhesions. 

the  abscess  had  not  developed  sufficiently  to  be  located 
and  drained  until  three  weeks  after  the  original  opera- 
tion. Fig.  23  shows  the  tube  in  place  surrounded  by 
gauze  pack;  sutured  margin  held  up  showing  parietal 
peritoneum  on  under  side. 

Fig,  24  is  a  diagrammatic  sketch  showing  the  layers 
incised  and  the  digital  method  of  preventing  pneumo- 
thorax until  the  diaphragm  and  the  chest  wall  edges  are 
united,     Pneumothorax,  all  statements  to  the  contrary 


THE    LTVER 


79 


notwithstanding,  is  always  a  very  serious  accident  even 
to  a  healthy  man  and  should  it  occur  during  an  operation, 
in  spite  of  all  precautions,  the  steps  of  the  operation 
should  be  completed  and  the  air  and  also  any  fluid  en- 
countered in  the  pleural  cavity  should  then  be  aspirated 


V 


Fig.  24. — Diagrammatic  sketch  showing  layers  incised  and  digital  method  of  temporarily 
preventing  pneumothorax  till  diaphragm  and  chest  wall  are  sutured. 

by  means  of  a  Potain  aspirator,  using  a  medium-sized 
cannula  with  a  blunt  end.  With  the  aid  of  a  differential 
pressure  apparatus  the  operation  can  be  done  very  easily 
and  rapidly  and  the  pressure  can  be  dispensed  with  as 
soon  as  the  pleural  cavity  is  closed.  The  usual  enlarge- 
ment of  the  right  lobe  narrows   or  even  temporarily 


80  TEOPICAL    SURGERY   AXD    DISEASES 

obliterates,  in  some  cases,  the  angle  of  the  pleural  space 
which  greatly  facilitates  the  operation.  The  right  lobe 
after  this  exposure  can  now  be  palpated  upwards  on  the 
dome  and  on  its  posterior  surface  downwards  and  for- 
wards; the  anterior  surface  and  margin  and  sometimes, 
if  not  greatly  enlarged,  the  under  surface  can  be  reached 
by  the  examining  fingers.  The  liver,  when  acutely  edem- 
atous, will  bulge  freely  into  the  wound,  is  bluish  in  color, 
and  soft  and  pulpy  to  touch.  The  indications  to  the 
exploring  fingers  of  underlying  abscesses  are  i)eritoneal 
adhesions  and  resistance  or  hardness  due  to  pus  tension. 
Before  iiicising-  an  abscess  or  before  exploring  with  the 
hollow  needte' and  syringe,  pack  off  with  a  ring  of  gauze 
which  may  be  fastened  in  jDlace  by  two  or  three  Xo.  1 
catgut  stitches  to  the  parietal  peritoneum,  although  this 
is  not  often  necessar^^;  sewing  to  the  liver  surfaces  is 
seldom  satisfactory. 

If  the  operator  prefers  to  wait  for  parietovisceral  ad- 
hesions before  oiDening  an  abscess,  if  the  condition  of 
the  patient  requires  it,  fasten  the  exploring  needle  in  situ 
as  the  cavity  may  not  be  readily  found  again  because  an 
edematous  liver  invariably  shrinks  very  rapidly  after 
any  operative  handling.  When  an  abscess  near  the  sur- 
face has  been  opened  and  its  cavity  can  be  reached, 
its  walls  should  be  palpated  for  neighboring  pus  collec- 
tions, supplemented  by  the  aspirating  needle,  and  if  the 
partition  between  cavities  is  not  too  thick,  it  can  be 
broken  down  by  a  long  forceps;  if  there  seems  too  much 
intervening  liver  tissue,  it  can  be  more  safely  left  to 
work  its  way  towards  the  opening  cavity  in  which  the 
tension  has  been  relieved,  when  it  can  be  opened  later  if 
it  does  not  open  spontaneously  by  confluence.  Open  deep 
abscesses  by  a  narrow  stab  incision,  using  the  needle  as  a 
guide  and  enlarge  the  opening  with  forceps  or  the  finger. 
As  soon  as  the  abscesses  are  opened,  insert  a  large  rubber 
tubular  drain,  stop,  and  put  the  patient  to  bed.    Flush- 


THE    LIVER  81 

iiig,  curetting,  sponging  out,  etc.,  are  all  contraindicated. 
The  causes  of  death  in  this  class  of  cases  are  too  often  due 
to  too  much  operating,  too  much  anesthetic,  too  much 
loss  of  blood,  and  consequent  shock.  These  operations 
can  be  suspended  at  any  moment  after  the  liver  has 
been  exposed  and  be  completed  later  under  local  an- 
esthesia. 

Treatment  of  Hemorrhage  from  the  Liver. — Normally 
the  liver  blood  pressure  is  very  low  but  in  a  considerable 
percentage  of  chronic  dysentery  cases  some  hepatic  con- 
dition has  developed  which  may  cause  enough  obstruc- 
tion and  consequent  increase  of  intravenous  portal  blood 
pressure  so  that  the  back  pressure  will  produce  in  liver 


Fig.    25. — Combination    drain    and    hemostat    for    liver   abscess. 

wounds  of  such  organs  the  most  furious  type  of  venous 
hemorrhage  ever  encountered,  and  unless  checked  im- 
mediatel}^  it  will  exsanguinate  the  patient  in  a  few  mo- 
ments. To  meet  this  emergencj^  a  combination  drain 
and  hemostat  was  devised  as  follows:  (See  Fig.  25)  A 
small,  firm,  red  rubber  catheter  is  passed  through  the 
wall  of  the  large  rubber  drain  from  its  lumen  outward, 
leaving  the  end  within  the  double  thickness  of  condon 
which  forms  the  bag.  To  avoid  occlusion  of  the  catheter 
from  constriction  by  the  puncture,  it  may  be  necessary  to 
take  away  a  bit  of  the  rubber  where  punctured  or  to 
burn  a  hole  that  will  be  small  enough  to  hold  the  catheter 
firmly  without  obstructing  it  and  at  the  same  time  snugly 


82 


TROPICAL    SURGERY   Al^D   DISEASES 


enough  to  prevent  the  escape  of  the  air.  This  apparatus 
might  also  be  used  to  advantage  instead  of  gauze  for 
wounds  after  excisions  of  a  portion  of  the  surface  of 
the  liver,  after  the  idea  of  Kousnetzoff  and  Penski,  who, 


Fig.    26. — Combination   drain   and    hemostat   inflated   in   a  liver   abscess   specimen.      For 
better  view  of  improved  apparatus,  see  Fig.  25.      (Author's  collection.) 

in  1894,  recomiiiended  a  continuous  suture  over  gauze 
packing  for  such  wounds.  Fig.  26  shows  another  but  in- 
ferior type  of  apparatus  distended  in  a  liver  abscess 
specimen.  The  advantages  of  this  siiniDle  and  always 
available  arrangement  are  that  it  acts  at  the  same  time 


THE    LIVER  ».:> 

as  a  drain  and  as  a  lieniostat;  it  can  he  inserted  and  in- 
flated in  a  few  seconds;  it  produces  efficient,  uniform  and 
equable  pressure  upon  all  parts  of  the  irregular  bleeding 
surfaces  of  any  tunnel  made  through  the  liver  substance 
either  to  open  an  abscess  or  for  a  trauma  from  any  other 
cause.    The  pressure  can  be  regulated  as  required,  can  be 


Fig.    27. — Liver.      Roundworm    invasion    through    large    common    duct,    showing    small 
abscesses.     Case   1   of  Dr.   Vernon  L,.  Andrews,   not  reported. 

easily  renewed  in  case  of  leakage  of  the  air  or  another 
apparatus  can  be  quickly  substituted  in  case  of  rupture 
of  the  balloon.  It  is  easily  removed  by  traction  on  the 
drainage  tube,  after  cutting  the  outside  silk  ligature 
which  inverts  the  bag  from  within  outward.  In  one  case 
the  Kelly  i^roctoscope  through  which  a  long,  wide,  dou- 


84 


TROPICAL    SURGERY   AND    DISEASES 


bled  gauze  bandage  was  T)acked,  controlled  an  alarming 
hemorrhage. 

''In  the  examination  of  liver  abscess  pus  for  Entameba 
histolytica,  the  pus  first  obtained  after  the  operation 
usually  does  not  contain  entamebse;  frequently  they  ap- 
pear in  the  pus  from  the  drainage  tube  only  after  several 
dsijs.  The  explanation  of  this  is  to  be  found  in  the  fact 
that  the  entamebse  are  not  found  in  the  pus  of  the  abscess, 


,,+  -,«■  «'V-5# 


Fig.    28. — L(iver.      Roundworm    invasion    through    large    common    duct,    showing    small 
abscesses.     Case  2  of  Dr.  ^'ernon  L.  Andrews,  not  reported. 

but  only  in  the  tissues  at  the  walls  of  the  abscess.  Con- 
sequently, it  is  only  when  the  walls  of  the  abscess  begin 
to  slough  oif  that  the  entamebag  appear  in  the  drainage 
from  the  abscess.  Therefore,  a  negative  diagnosis  of  eii- 
tamebic  liver  abscess  should  never  be  made  except  after 
negative  examinations  obtained  for  several  successive 
days  after  operation."     (Walker.) 

Occasionally  round  worms  will  find  their  way  to  the 


THE    LlVEIl  50 

liver  when  the  common  duct  has  become  dilated;  they 
have  never  been  recognized  during  life,  but  have  been 
discovered  i)ostmortem  in  a  few  cases.  (See  Figs.  27 
and  28.)  Flukes  of  several  species  have  also  been  found 
occasionally. 

For  the  most  recent  information  on  cosmopolitan 
hepatic  conditions,  reference  is  made  to  the  article  on 
''The  Liver  and  its  Cirrhoses,"  hj  Dr.  William  J.  Mayo, 
in  the  Journal  of  the  American  Medical  Association, 
May  11,  1918. 


CHAPTER  V 

GYXECOLOGY  AND  OBSTETRICS 

About  fifty  per  cent  of  all  surgical  cases  encountered 
among  the  natives  of  the  Philippines  belong  to  so-called 
gynecology.  The  varieties  of  pathology  found  and 
the  causes  of  diseases  peculiar  to  native  women  do  not 
differ  materially  from  those  in  America,  not  excepting 
hygienic  conditions,  general  and  local,  although  civiliza- 
tion, education,  and  social  conditions  so  often  a  factor  are 
supposed  to  be  greatly  inferior  to  those  in  the  United 
States.  It  has  not  yet  occurred  to  the  natives  that  limita- 
tion of  offspring  is  a  good  thing  sometimes  and,  being 
religiously  opposed  to  criminal  abortion,  it  also  has  not 
become  established  as  custom  or  as  fashion.  The  very 
unhygienic  conditions  under  which  childbirth  takes  place 
and  the  ignorant,  brutal,  and  meddlesome  midwifery 
make  for  numerous  lacerations  of  the  birth  canal  and 
enough  infection  to  bring  up  the  average  of  pelvic  inflam- 
matory disease  to  perhaps  more  than  that  of  their  more 
civilized  white  sisters  who  are  indebted  to  a  greater  ex- 
tent to  the  gonococcus  for  these  troubles.  When  labor  is 
not  accelerated  by  violent  means,  traumatism  is  slight,  as 
the  babies'  heads  are  small  and  infections  are  infrequent. 

A  tight  cord  is  often  worn  about  the  waist  ''to  keep  the 
child  small;"  this  almost  cuts  the  body  of  the  mother  in 
two  at  times;  a  woman  must  work  hard  during  pregnancy; 
the  native  midwife  makes  frequent  examinations  for  five 
cents  each  and  ''changes  the  baby  around;"  the  super- 
stitions of  the  very  ignorant  are  of  the  most  terrifying 
nature ;  the  inother  rareh'  knows  when  the  baby  is  coming 
and  is  seldom  prepared  for  it ;  during  labor  she  is  kneeled 
on,  squeezed,  and  rammed  by  wooden  or  stone  clubs  which 

86 


GYNECOLOGY    AND    OBSTETRICS 


are  sold  for  the  purpose  in  tlic  markets;  (luring  partui-ition 
a  rope  is  looped  around  the  hody  aV)Ove  the  uterus  "to 
keep  the  child  from  goini;-  up"  and  the  ends  are  pulled  on 


Fig.    29.— Ovarian    cysts.      <  I'lirjlograpli   in'    Dr.    R.    U.    Castor,    of    Sweljo,    Burma.) 

SO  strongly  by  two  men  that,  in  one  case  I  saw,  the  ribs  on 
both  sides  were  fractured;  the  placenta  is  pulled  away  by 
the  cord,  or  if  it  does  not  come  in  about  an  hour,  the 


8s  TROPICAL    SURGERY    AND    DISEASES 

cord  is  cut  short.  The  placenta  when  burned  with  paper 
and  pen  under  the  house  assures  an  ''ilhistrious"  child 
and  a  placental  soup  for  the  mother  prevents  all  compli- 
cations. The  tight  rope  about  the  body  is  kept  snug 
during  labor  'Ho  prevent  the  breath  and  blood  mixing 
together ; "  a  band  is  cinched  up  about  the  pelvis  by  strong 
men  to  keep  her  from  falling  apart;  bleeding  is  encour- 
aged by  making  the  patient  sit  up;  she  is  stuffed  with 
food  and  under  no  circumstances  is  she  allowed  to  sleep 
for  three  days  or  she  will  become,  "loca,"  (insane);  the 


Fig.    30. — A    six    months'    abdominal    lithopedion,    carried    seven    years:    a    second    and 
smaller    one   was    found   in   the   pelvis.      (Author's    collection.) 

uterus  is  then  ''put  back"  and  smoked  over  an  herb  fire 
to  dr}^  up  its  rawness  and  for  three  months  she  can  not 
take  a  cool  bath. 

The  baby  comes  in  for  his  share  of  attention  also,  as 
may  be  believed  from  the  statistics  which  show  a  mortal- 
ity of  65  per  cent  in  infants  under  one  year  of  age.  These 
were  the  obstetric  customs  in  the  province  in  which  I  was 
stationed  in  the  early  days  of  American  occupation,  but 
they  are  being  rapidly  changed  through  educated  native 
medical  men  and  nurses  as  the  Filipinos  are  very  quick 
to  learn  and  to  appreciate  improvements. 


GYNECOLOGY    AND    OBSTETRICS  89 

Tuberculosis  and  malignant  affections,  dermoid  and 
every  variety  of  ovarian  cyst  are  common  and  as  sur- 
gery in  the  provinces  is  not  often  resorted  to,  some  ex- 
treme cases  are  seen  (Fig.  29).  Among  tlie  curiosities 
encountered  was  a  double  lithopedion  in  a  woman  tliirty- 
six  years  of  age  whicli  was  carried  seven  years;  the 
abdominal  specimen,  a  six  months '  child,  was  swung  high 
up  in  the  omentum  and  draped  about  with  many  coils  of 
small  intestines  (Fig.  30) ;  the  pelvic  specimen  in  the 
right  tube  was  8  cm.  (314  inches)  long  b}^  3.5  cm.  (IV2 
inches)  through;  each  was  a  firm  stony  mass  except  where 
some  adipocere  and  mummification  occurred.  Fibroids 
are  common  in  all  parts  of  the  uterus;  probably  over 
twenty  per  cent  of  native  women  have  fibroids,  but  less 
than  five  per  cent  of  these  have  symptoms  or  apply  for 
treatment.  The  patients  ,are  very  tractable  and  react 
from  the  most  extensive  operations  very  satisfactorily. 


CHAPTER  VI 

GEXITOUEINARY 

In  the  Philippines,  vesical  and  renal  calculi  were  very 
common  but  prostatic  hypertrophy  was  never  observed. 
Venereal  disease  was  not  common,  but  cancer  of  the  penis 
was  rather  frequent.  I  reported  amebic  infection  of  the 
urinary  bladder,  without  rectovesical  fistula,  in  1904;  the 
source  of  the  infection  was  traced  to  the  use  of  an  un- 
clean catheter  which  was  employed  in  irrigating  the  bowel 
of  other  patients  for  entamebic  dysentery;  when  the  pa- 
tient entered  the  hospital  for  pain  in  the  lumbar  region, 
the  urine  was  normal ;  after  daily  irrigations  for  ten  days 
and  one  exploration  for  stone  on  the  seventh  day,  lie  com- 
plained of  dysuria,  hematuria  and  severe  pain  at  the  end 
of  micturition;  large  motile  amebas  Avere  found  in  his 
urine;  amebas  were  positive  for  a  month;  there  were  no 
amebas  in  his  stools;  a  daily  irrigation  with  1:500  up  to 
1 :100  solution  of  quinine,  five  to  six  ounces  of  which  could 
be  retained  from  two  to  five  hours,  cured  the  condition, 
Lynn  of  Costa  Rica  also  reported  a  case  (1914)  infected 
by  a  syringe  previously  used  in  the  rectum  and  -six  cases 
were  said  to  have  occurred  in  the  military  base  hospital 
in  Manila  (1900-1904)  but  the  data  could  not  be  found 
of  record. 

TROPICAL  FISTULiE  IN  ANO 

Maxwell,^  of  Formosa  (1912),  reports  multiple  deep 
fistulous  tracks  of  the  buttocks  which  are  not  common; 
two  or  three  cases  a  year  occurred  in  8,000  cases.  It 
commences  as  a  fistulo-in-ano;  as  it  is  painless  the  cases 
are  neglected  and  become  very  extensive;  some  are  of 

^Maxwell,  J.   L.:     Trans.   Soc.  Trop.  Med.   and  Hyg.,   1912,  vi,  No.   2,  p.   50. 

90    - 


GENITOURINARY  91 

five  years'  duration;  incision  and  curettage  do  not  help 
and  excision  is  impracticable  on  account  of  the  extent  of 
the  disease ;  they  were  not  tuberculous  and  no  fungi  could 
be  detected,  but  large  amebas  were  found  in  every  case. 
Ulcers  of  the  rectum,  perirectal  abscess  and  fistulas  due 
to  amebas  were  common  in  the  Philippines  in  the  early 
days  but  no  such  condition  as  Maxwell  describes  was  ob- 
served. Kartulis  described  a  similar  condition  in  Egypt 
due  to  a  blastomycosis  of  the  gluteal  region,  later  ob- 
served by  Castellani  in  Ceylon,  in  which  a  saccaromyces- 
like  organism  was  found;  he  claimed  that  the  sinuses 
did  not  communicate  with  the  intestines.  In  Maxwell's 
cases  the  amebas  may  have  wandered  in  from  the  bowel. 


CHAPTER  VII 
CATASTROPHE  AND  EMERGENCY  SURGERY 

Emergency  surgery  included  man}^  and  extensive  in- 
cised wounds  due  to  tlie  fiery  temper  of  tlie  native  and 
his  fondness  for  the  bolo  and  dagger  in  settling  disputes. 

The  eruption  of  Taal  volcano,  forty  miles  south  of 
Manila,  on  January  30,  1911,  at  half  past  two  in  the 
morning,  furnished  the  most  extensive  experience  in 
catastrophe  work. since  the  American  occupation  of  the 
Islands.  Fifteen  hundred  people  were  killed  and  sev- 
eral hundred  burned;  about  two  hundred  of  the  worst 
cases  were  brought  to  the  hospital  in  Manila  several  days 
later.  The  burns  were  of  every  degree  of  the  exposed 
parts  of  the  body  and  nearly  all  were  infected;  the  pain 
complained  of  was  not  excessive  and  slow  recovery  under 
picric  acid  dressings  was  the  rule.  Some  of  the  patients 
at  a  distance  from  the  volcano  described  their  burns  as 
due  to  a  rain  of  mud  that  was  not  hot  but  seemed  to  con- 
tain some  escharotic;  others  near  the  volcano  attributed 
their  burns  to  the  force  of  a  blast  of  hot  wind  filled 
with  hot  sand  and  ashes  that  lasted  ten  or  fifteen  minutes, 
followed  by  a  shower  of  ashes,  a  deluge  of  hot  mud  and 
lava  and  later  by  a  downfall  of  rain.  Many  other  injuries 
besides  burns  occurred;  one  of  the  hospital  cases  seen 
was  as  follows :  The  house  of  Seuora  Apolonia  Solis,  on 
the  hanks  of  Taal  Lake,  was  swept  into  the  water  and  she, 
carrying  a  child  at  term,  while  swimming,  was  deejDly 
cut  on  the  head  and  groin  b}"  a  flying  piece  of  metal 
roof;  her  baby  was  born  that  morning;  her  wounds  healed 
nicely  later  and  mother  and  child  survived. 

Another  wholesale  jjrostration  of  people  occurred  one 
Sunday  after  the  masses  celebrating  Saint  John's  day, 

92 


CATASTROPHE    AND    EMEllGP^NCY    SURGERY  93 

when  it  was  the  custom  to  bathe  in  the  sea.  The  beach 
was  crowded  Avith  natives  writhing  in  agony  from  tlie 
effects  of  jelly  fish  poisoning.  Some  of  them  were  para- 
lyzed by  the  poison  and  may  have  died;  all  suffered 
intensely;  the  superficial  effects  on  the  skin  of  some  white 
persons  whose  feet  and  legs  only  came  in  contact  with  the 
jelly  fish  masses,  were  an  intense  burning  and  reddening; 
the  general  symptoms  which  were  alarming  were  heart 
failure,  a  complete  loss  of  strength,  and  nausea.  Treat- 
ment was  morj)hine,  diffusible  stimulants,  soap  and  fresh 
water  cleansing,  and  soothing  applications  to.ihe  skin. 
Stitt  called  attention  to  the  fact  that  these  fish  must  pos- 
sess various  degrees  of  venom  and  cited  the  case  of  a 
powerful  American  naval  employee  who  dived  overboard 
to  refresh  himself  and  was  killed  instantly.  The  other 
principal  under-water  danger  to  man  is  sharks. 

Some  of  the  military  surgery  of  which  a  great  deal 
was  handled  during  the  campaigns  of  1898-1902  was 
unusual  and  interesting  on  account  of  the  native  weapons, 
and  might  properly  be  classed  as  emergency  surgery. 
Gas  gangrene  and  tetanus  were  not  uncommon  either 
among  soldiers  or  in  civil  life. 

Snake  bites  are  not  a  feature  of  Philippine  accidents, 
as  the  principal  venomous  varieties  although  represented 
are  neither  numerous  nor  active.  The  pythons  which 
kill  by  constriction  grow  to  over  30  feet  in  length,  are 
terrifying  to  contemplate  but  are  sluggish;  this  lethargy, 
however,  is  not  always  shared  by  beholders.  I  saw  a 
squad  of  five  soldiers  do  a  half  mile  in  two  minutes  flat 
over  bad  ground,  immediately  after  having  slid  down  a 
river  bank  almost  on  top  of  a  monstrous  old  serpent 
coiled  up  in  the  sun  in  the  dry  bed  of  the  stream, 
probably  digesting  his  last  .  month 's  meal ;  as  soon 
as  they  could  overcome  their  momentum  they  went  back 
and  got  him.     Young  pythons,  six  or  seven  feet  long, 


94  TROPICAIi    SUEGERY    AXD    DISEASES 

used  to  be  vended  by  native  boys  as  ratters,  for 
about  five  dollars  Mexican;  placed  in  the  attic  of  a 
house  which  seems  to  be  his  town  domicile  of  choice,  he 
forages  for  himself  and  keeps  the  premises  rat-free.  The 
only  evidence  of  his  presence  will  be  an  occasional  racket 
when  in  combat  with  an  intruding  cat  or  a  wet  spot  which 
shows  on  the  ceiling  if  of  bamboo  matting.  When  it  is 
bad  hunting  indoors,  he  is  apt  to  fare  forth  at  night  and 
rob  the  hen  roost;  he  may  even  find  an  affinity  and  furnish 
unwelcome  additions  to  the  family,  but  the  worst  thing 
he  does  is  to  lie  down  and  die  between  Avails  and  pollute 
the  air  most  tremendously.  House  snakes  were  not  popu- 
lar with  Americans,  especially  not  with  women  who  had 
babies,  and  there  was  small  demand  for  them.  Their 
power  of  constriction  is  very  great.  In  the  early  days  of 
military  occupation  a  small  boy  carrying  a  six  foot  snake 
wound  around  his  body  was  exhibiting  him  to  some  offi- 
cers, in  front  of  the  Oriente  Hotel  in  Manila.  The  offi- 
cers annoyed  the  reptile  so  much  by  prodding  him  with 
their  sticks  that  he  closed  down  on  the  lad  and  crushed 
him  so  severely  that,  it  was  said,  he  died  later.  Awakened 
one  night  during  a  typhoon  by  crashing  glass  and  falling 
objects  I  arose  and  slew  an  eight  foot  specimen,  glitter- 
ing and  beautiful  in  a  brand-new  coat,  in  my  bedroom, 
where  he  had  lost  his  way  on  his  reascent  to  the  roof. 

There  are  no  dangerous  wild  beasts  except  the  wild 
carabao  or  water  buffalo,  which  when  hostile  has  no 
match  for  ferocity;  one  must  either  kill  him  or  take  to 
a  tree,  and  that  forthwith,  or  be  killed,  for,  although 
Aveigliing  about  a  ton,  he  is  as  quick  as  a  tiger.  Other- 
wise the  country  is  a  hunter's  paradise,  swarming  with 
game  of  all  sorts.  Heat  prostration  in  the  Philippines 
is  practically  unknown.  Leeches  work  through  any  foot- 
wear excejDt  boots.  The  bleeding  from  their  bites  is  very 
persistent  and  can  be  stopped  only  by  continuous  pres- 
sure. 


CHAPTER  VIII 
FILARIASIS 

The  filaria  nematodes,  excepting  the  malarial  Plas- 
modia and  amebas,  are  the  most  widely  distributed  para- 
sites of  the  torrid  zone,  and  are  also  found  occasionally 
in  the  United  States  and  Europe.  Certain  mosquitos 
which  act  as  the  intermediate  hosts  for  the  filarial  dis- 
eases of  surgical  importance  were  experimentally  deter- 
mined by  Manson,  Bancroft,  and  others.  The  embryo 
nematodes  of  Filaria  bancrofti  in  the  blood  of  the  human 
host  are  taken  in  by  the  various  species  of  Culex  and 
Anopheles,  and  undergo  in  these  insects  the  changes 
necessary  for  reinoculating  man  during  a  subsequent 
feeding;  consequently,  it  is  of  the  greatest  importance 
whenever  a  case  is  discovered  to  protect  the  mosquitos 
against  infection  by  screening  off  the  parasitized  person. 
The  innumerable  embryos  in  the  peripheral  circulation 
are  never  the  pathogenic  agents  of  so-called  filarial  con- 
ditions.    (Figs.  31,  32  and  33.) 

Captain  Phalen  and  Lieut.  Xichols^  of  the  United  States 
Army  Tropical  Board  in  1908-1909,  made  about  7,400 
blood  examinations  in  various  localities  of  the  Philip- 
pines to  get  an  idea  of  the  prevalence  and  distribution 
of  filaria,  and  found  it  to  represent  two  per  cent  of  infec- 
tions for  the  islands;  thirty-five  cases  had  elephantoid 
disease.  Protection  from  mosquitos  is  preventive  but 
this  is  impracticable  for  a  native  population,  hence  when- 
ever a  case  is  discovered  among  the  native  employees  of 
foreigners,  it  should  be  discharged  at  once  as  the  Culex 
fatigans  Wied.,  which  transmits  the  disease,  is  omni- 
present. 

^Phalen,  Jos.  M.,  and  Nichols,  Henry  T.:  Philippine  Tour.  Sc.,  1908,  Sec.  B,  iii, 
305;  1909,  Sec.  B,  127. 

95 


96 


TROPICAL    SURGERY   AXD    DISEASES 


Fig.  31. — Filaria  nocturna,  X  about  390  (double  exposure).  Showing  the  general 
morphology  and  the  viscus-like  organ  at  the  junction  of  the  middle  and  posterior  thirds 
cf  the  parasite  (Wherry  and  ]\IcDill).*  (Photomicrograph  by  Charles  Martin,  Manila, 
photographer,    Bureau   of   Government   lyaboratories.) 


Fig.  32. — Head  end  of  Filaria  nocturna,  X  about  880.  The  sheath,  the  three  duct- 
like threads  connecting  the  anterior  end  of  the  viscus-like  organ  with  the  head  end 
of  the  embryo,  and  the  transverse  striations  of  the  musculo-cutaneous  layer  may  be 
seen  (Wherry  and  i\IcDill).*  (Photomicrograph  by  Charles  Martin,  Manila,  photog- 
rapher.  Bureau   of  Government  I^aboratories.) 


^Reprinted  from  Jour.   Infect.   Dis.,  June  24,   1905,  vol.  ii,  Xo. 


pp.   412-420. 


FILARIASIS 


97 


A. — Represents  a  dead  fil- 
aria,  showing  granular  de- 
generation. 

B. — Drawn  from  a  filaria 
just  before  granular  degen^ 
eration  set  in.  Proportions 
about  correct  as  seen  with 
the  Zeiss  1/12  oil  im.,  comp. 
oc.  8.  Length,  0.330  mm.; 
breadth,  0.00765  mm.  The 
distances  between  the  anatom- 
ical markings  were  as  fol- 
lows: A-B,  97.92  n;  B-C, 
S3. 55  n;  C-D,  61.20  11;  D-E, 
64.26  /*;  E-F,  53.55  /i;  total, 
330.48  II,  or   0.33   mm. 

C. — Head  end  of  filaria, 
showing  retracted  lips  and 
spicule. 


Fig.  33. — Filaria  nocturna.     (Wherry  and  McDill* — Figures  redrawn  by  T.  Espinosa 
from  original  drawings.) 


'Reprinted  from  Jour.  Infect.  Dis.,  June  24,   1905,  vol.  ii,  No.  3,  pp.  412-420. 


98  TROPICAL   SURGERY   AlSTD   DISEASES 

Medical  Treatment. — Many  drugs  have  been  employed 
empirically  without  success.  The  most  promising  inter- 
nal treatment,  aimed  at  the  death  of  the  joarent  worm, 
is  the  new  arsenical  antiluetic  preparations,  arsenoben- 
zol,  ''606,"  and  anilarsenate  of  sodium,  "Atoxyl,"  of 
which  10  to  15  drops  of  a  10  per  cent  watery  solution  is 
given  h^^odermically  every  day  or  every  other  day  for 
six  weeks.  Failure  of  the  embryos  to  reappear  in  the 
blood  after  one  and  two  years,  following  such  arsenical 
treatment,  can  be  taken  as  presumptive  evidence  that 
the  parent  worm  has  been  destroyed;  if  further  experience 
shows  this  treatment  to  be  effective,  an  early  destruction 
of  the  parasites  will  prevent  the  development  of  the  hojoe- 
less  conditions  now  found  in  chronic  cases. 

Clapier  (Les  loorteurs  de  Kystes  filariens  (Onchocerca 
volulus  et  de  Xodosites  Juxta-Articulaires  en  pays  Toma 
(Region  militaire  de  la  Guinee),  Bull.  Soc.  Path.  Exot., 
February,  1917,  vol.  X,  No.  2,  pp.  150-157)  describes  a 
common  subcutaneous  cystic  tumor  in  the  Toma  country 
which  separates  Liberia  from  the  rest  of  French  Guinea. 
They  are  of  slow  groT\i;h,  vary  in  size  from  a  shot  to  a 
small  orange,  very  firm,  rounded,  generally  multiple, 
not  painful  to  pressure — or  slightly,  slight  tendency  to 
suppuration.  These  signs  are  conunon  to  both  the  juxta- 
articular  and  the  volvulus  cysts;  the  juxta-articular, 
however,  are  very  firm  or  hard,  neighboring  tissues 
puffy,  less  regular  in  contour,  i^refer  to  localize  on  bon}^ 
epiphyses,  have  a  definite  tendency  to  symmetry  (see 
Figs.  65  and  66)  and  are  often  adherent  to  the  perios- 
teum, whereas  the  volvulus  cysts  are  elastic,  regular  in 
shape,  neighboring  tissues  not  puffy,  not  clearly  con- 
nected with  bones  or  joints  but  localized  in  inguinal  fold, 
pubes,  ribs  and  scapula.  There  is  little  tendency  to  s^mi- 
metry  and  they  are  generall}^  movable.  Exploratory 
puncture  A^dll  confirm  the  diagnosis ;  in  the  nodules  there 
is  no  fluid,  in  the  cysts  is  a  thick  viscous,  grayish,  yellow 


FILAEIASIS  99 

or  orange  fluid  rich  in  microfilariae;  the  cj^'st  cavities 
are  partly  filled  with  tangled  threads  attached  to  the 
walls;  these  are  the  adult  worms;  the  females  are  con- 
nected with  the  walls,  the  males  are  free.  The  nodules 
are  white  on  section  and  fi.brous  and  there  is  no  cavity. 
Juxta-articular  nodules  appear  to  have  more  than  one 
origin,  a  nocarclia  (Madagascar)  and  in  Nyasaland, 
yaws. 

Elephantiasis 

The  specific  factors  are  perhaps  rarel}'  the  parent 
worms  of  filaria,  although  five  and  six  worms  have  been 
found  blocking  the  l^rmphatics  (Castellani) ;  usually  some 
undetermined  microbial  causes  exciting  an  obliterative 
inflammation  or  secondary  and  frequent  invasions  of  the 
deeper  parts  by  the  skin  diplococcus  and  other  patho- 
genic organisms  are  the  actual  causes  of  chronic  obstruc- 
tion of  the  hanphatic  and  venous  circulations  of  any 
blocked  off  area;  these  with  the  resulting  characteristic 
fibromatosis  changes  in  the  hypoderm  produce  what  we 
call  elephantiasis.  The  following  case  is  t}7)ical  of  so- 
called  beginning  cases  and  strongly  suggests  streptococ- 
cus infection. 

American,  thirty-three  years  old,  resident  of  the  Philip- 
pines ten  years,  married  to  a  native  woman;  in  1906  he 
began  to  have  attacks  of  chills  and  ten  day  fever  with 
pain  every  two  or  three  months  in  the  right  lower  ex- 
tremity beginning  in  the  foot,  which  became  swollen,  hot 
and  tender;  this  case  suggested  clinically  nothing  so 
much  as  a  chronic  submerged  erysipelas,  according  to 
Sabouraud,  Unna,  and  others.  In  1911  the  increasing 
size  of  the  limb  brought  him  to  the  hospital.  Numerous 
attempts  to  find  embryos  in  the  blood  at  night  or  in  the 
tissues  of  the  swollen  limb  failed.  After  rest  in  bed  and 
bandaging  for  two  weeks  the  skin  became  elastic;  long 
double  Xo.  14  silk  was  looped  subcutaneously  from  over 


100 


TROPICAL    SURGERY    AND    DISEASES 


the  instep  in  front  to  the  inguinal  and  hypogastric  re- 
gions above,  and  another  loop  was  passed  behind  from 


Fig.    34. — Beginning   elephantiasis    in   an   American    in    Manila.       (Author's    collection.) 

just  above  the  heel  to  the  region  of  the  buttocks  into 
healthy  subcutaneous   spaces,   according  to   Handley's" 


^Handley,  W.  Sampson:     Hunterian  Lectures,  Brit.  Med.  Jour.,   1910. 


riLAPJASIS 


101 


method  of  lymphangioplasty.  The  improvement  after 
six  months  was  not  so  apparent  as  in  the  weeks  imme- 
diately following  the  operation,  but  the  patient  claimed 
that  he  was  much  more  comfortable  (Fig.  ?A).  In  the 
true  clironic  elephantiasic  condition  or  elephantiasis  nos- 
tras streptogenes  there  is  no  fever,  the  skin  is  hard  and 
verrucose  and  the  overgrowth  in  some  cases  is  enormous 
(Fig.  35). 


Fig.    35. — Chronic    elephantiasis   nostras    streptogenes    of    scrotum    and    leg. 
(Deschien's   Atlas.) 

The  prominent  clinical  feature  is  lymphatic  and  venous 
obstruction  with  lymphedema;  numerous  surgical  proce- 
dures have  been  attempted  for  its  relief.  Limited  excision 
has  been  unsatisfactory.  Sir  Havelock  Charles  removed 
the  diseased  tissue  entire  from  the  foot  to  knee  and  skin- 
grafted  the  surface  with  a  good  result.  Castellani'  claims 
good  results  in  selected  cases  by  complete  three  to  six 

^Castellani:     Brit.  Med.  Jour.,  1908,  ii,   1361. 


102 


TROPICAL    SURGERY   AND    DISEASES 


months'  rest  lying  down,  firm  equable  continuous  pres- 
sure by  very  carefully  applied  bandages  and  daily  injec- 


t£l^. 


/ 


"'•        i-mrnH^ 


Fig.  36. — A  case  of  neurofibromatosis  in  a  woman  thirty  j'ears  old  resembling 
elephantiasis.  "Klephantiasis  Nervorum."  (Unpublished  photo  from  Dr.  R.  H.  Castor, 
of  Swebo,  Burma.) 


tions  deep  into  the  affected  parts  of  2  to  4  c.c,  in  water 
of  ''fibrolysin"  which  is  a  mixture  of  thiosinamiii  and 


riLARIASlS  Wo 

salicylic  acid.  This  treatment  renders  the  skin  clean, 
loose,  and  flexible,  so  that  long  strips  can  be  resected 
aseptically.  Elastic  support  must  be  worn  to  prevent 
relapse.  When  the  parts  attain  enormous  size,  there  is 
nothing  to  offer  but  amputation.  Matas*  (1913)  in  re- 
viewing the  treatment  of  elephantiasis,  reminds  us  of  the 
failure  of  ligation  of  the  main  artery  advocated  by  Car- 
nochan  in  1851  and  of  the  more  recent  multiple  cuneiform 
excisions  of  skin  and  underlying  fibromatous  tissue  by 
Kuznetzoff  (1905)  and  others,  with  favorable  results  in 
a  certain  number  of  cases.  Handley's  silk-lymphangio- 
plasty  has  not  given  good  results  after  extensive  trial  by 
many  surgeons.  Le  Nourmant  pointed  out  that  no  matter 
how  ancient  or  aggravated  elephantiasic  states  may  be, 
the  tissue  lesions  are  limited  by  the  derm  and  hypoderm 
and  do  not  extend  below  the  deep  aponeurosis  where  the 
tissues  retain  their  normal  circulation  and  are  capable  of 
taking  care  of  the  stagnant  lymph  above  the  aponeurotic 
partition,  provided  an  opening  is  established  between 
them. 

Lanz^  of  Amsterdam  in  1906,  improved  on  Handley's 
method  by  the  formation  of  communications  of  subcuta- 
neous and  deej)  muscular  and  periosteal  lymph  channels  to 
within  the  bone;  he  fenestrated  the  fascia  lata,  trephined 
the  femur  and  passed  flaps  of  the  fascia  down  through 
the  muscles  and  into  the  medullary  canal,  with  excellent 
results.  Oppel,  of  St.  Petersburg,  extended  this  method 
to  the  tibial  and  crural  points  without  opening  the  bone. 
Rosanow,°  of  Moscow,  shows  by  a  case  in  which  he  ob- 
tained a  good  and  an  apparently  lasting  result,  that  deep 
triangular  and  rhomboid  flaps  of  fascia  tucked  between 
underlying  muscles  may  bring  about  a  drainage  and  cure 
of  elephantiasis;  Kondeleon"   (1912)  removes  large  sec- 

■*Matas,  R. :  Surgical  Treatment  of  EJlepliantiasis,  Am.  Tour.  Trop.  Dis.,  July, 
1913,  60. 

=Lanz,  0.:     Zentralbl.  f.  Chir.,  Jan.  7,  1911,  3. 

"Rosanow:     lyymphangioplasty  in  Elephantiasis,  Arch.  f.  Clin.   Chin,  1912,  xcix. 

"Kondeleon:     Miinchen.   med.   Wchnschr.,   Dec.   10,   1912,  26. 


104  TROPICAL    SURGERY    AND    DISEASES 

tions  of  the  fascia  lata  in  the  thigh  and  leg,  claiming  that 
permanent  new  anastomotic  channels  are  formed  between 
the  lymph  spaces  above  and  below  the  site  of  the  re- 
moved aponeurosis  and  his  six  cases  in  Athens  support 
his  contention.  Matas,^  and  Gessner,  each  made  a  limited 
Kondeleon  operation  on  one  case  with  marked  improve- 
ment. The  possibilities  of  repeated  injections  of  anti- 
streptococcal  polj^valent  serum  which  gave  such  satis- 
faction in  one  of  Matas'  cases  should  not  be  forgotten, 
nor  the  autogenous  vaccines  made  from  the  mycotic  in- 
vaders of  the  deeper  tissues.  Charles,^  in  India,  has  suc- 
cessfully operated  upon  several  hundred  cases  of  scrotal 
elephantiasis  by  complete  ablation  of  all  diseased  skin 
and  tissue,  carefully  preserving  the  return  circulation  of 
the  penis;  he  then  covers  the  denuded  parts  and  testicles 
to  the  base  of  the  penis  by  sliding  adjacent  healthy  skin; 
the  penis  is  covered  by  Thiersch  grafts.  His  mortality 
was  one  per  cent. 

Chylous  Ascites,  Chylothorax,  and  Chylocele 

These  are  not  common  conditions,  but  are  occasionally 
recognized  by  the  presence  within  the  peritoneal,  pleural 
or  tunica  vaginalis  testis  sacs  of  a  milky  fluid,  which,  if 
chyle,  rejDresents  some  injury  to  the  large  lymph  vessels; 
if  the  chyliform  fluid  contains  only  degenerated  epithe- 
lium fat  and  i^us  cells,  it  is  usually  an  exudate  from  a  con- 
cealed cancer  or  tuberculosis.  The  surgical  treatment 
of  true  chylous  collections,  if  the  lesion  in  the  vessel 
does  not  close  spontaneously  under  watchful  waiting,  is 
that  of  other  effusions  into  these  cavities;  a  chylocele 
can  be  overcome  by  any  of  the  methods  devised  for  the 
cure  of  hydrocele;  a  chylothorax,  if  persistent  and  due 
to  loss  of  absorptive  power  of  the  pleura  or  failure  of 
the  lymph  vessel  lesion  to  close,  will  require  some  modi- 


sCharles.   R.   H. :      Indian  Med.    Gaz.,    1901,   xxxvi.    84. 


FILAllIASIS  105 

ficatioiis  of  Handley's  and  Kondeleon's  operations. 
Ascites  of  the  peritoneal  sac  when  there  is  no  pliysiologic 
objection  to  draining  it  bade  into  the  general  circulation, 
is  often  manageable  by  an  epiplopexy  devised  by  Talma, 
Drummond  and  Morrison  (1896)  or  by  several  other 
procedures  originated  since,  but  the  average  death  rate 
of  these  procedures  has  been  about  20  per  cent.  Schiassi 
fixes  the  siDleen  and  omentum  in  a  recess  of  the  abdom- 
inal wall.  Mayo  places  the  omentum  anterior  to  the  pos- 
terior sheath  of  the  rectus  by  burrowing  between  two 
incisions,  one  over  the  liver  and  one  10  cm.  (4  inches) 
lower. 

Narath's  method  is  very  jDopular.  Under  local  anes- 
thesia the  fluid  is  let  out  through  an  incision  above  the 
umbilicus;  a  thumb  sized,  10  cm.  (4  inch)  long  piece  of 
omentum  is  drawn  out,  avoiding  tension  on  the  colon; 
the  peritoneum  is  sutured  around  the  base  of  the  piece 
of  omentum  and  the  rest  of  it  is  placed  in  a  subcutaneous 
pocket  to  the  left.  There  is  nothing  to  prove  the  theory 
that  the  good  results  after  these  operations  are  from 
collateral  circulations,  while  there  is  much  to  show  that 
the  fluid  finds  its  way  directly  to  the  subcutaneous  spaces 
alongside  the  herniated  organs  where  they  have  produced 
a  defect  in  the  abdominal  wall,  which  opens  under  pres- 
sure. Eck's  fistula  between  the  portal  vein  and  the 
inferior  vena  cava  is  not  only  difficult  but  when  accom- 
plished has  been  followed  by  alimentary  intoxication  and 
death.  Gall  bladder  drainage  is  indicated  in  the  obstruc- 
tive billiary  type  of  toxic  cirrhosis  with  ascites;  this 
type  has  been  produced  experimentally  many  times. 

Wynter  tried  femoral  canal  drainage,  operating- 
through  a  trocar  wound  after  tapping,  but  it  was  diffi- 
cult and  tedious,  a  general  anesthetic  was  required,  the 
opening  was  liable  to  be  blocked  at  any  time  by  omentum 
or  intestine,  or  it  would  be  sealed  by  reparative  processes. 
Wynter  also  planted  a  flanged  silver  eyelet  with  a  7  mm. 


106  TEOPICAL  SURGERY  AXD  DISEASES 

(1/4  inch)  Avide  opening  subcutaneously  in  the  linea  alba, 
but  it  and  other  devices  of  this  tjj)e  proved  failures. 

Henschen,°  after  two  efforts  to  provide  drainage  for 
ascites  in  a  stomach  cancer  case,  made  a  tunnel  from  an 
incision  above  the  left  spine  of  the  ilium  through  the 
abdominal  wall  to  a  median  incision  opening  into  the 
peritoneal  cavity;  the  mouth  of  an  ordinary  rubber  con- 
dom Avas  then  sutured  to  the  opening  in  the  peritoneum, 
the  condom  was  drawn  through  the  tunnel  and  the  blind 
end  cut  oif,  leaving  it  projecting  the  width  of  a  thumb 
above  the  plane  of  the  externus  aponeurosis;  this  end 
was  then  spread  out  into  a  ring  and  sutured  to  the 
aponeurosis,  and  the  skin  was  closed.  The  immediate 
result  was  an  extensive  edema  around  to  the  middle  of 
the  back,  the  ascites  was  kept  down,  and  the  pressure  dis- 
turbances of  the  heart  and  lungs  subsided  entirely.  If 
the  omentum  is  sutured  out  of  the  way,  the  drainage 
might  persist  in  this  operation  but  the  hernia  liability 
must  be  considerable. 

Dobbertin,^°  under  local  anesthesia,  ligates,  divides,  and 
turns  up  about  5  cm.  (2  inches)  of  the  saphenous  vein 
below  Poupart's  ligament,  passes  it  upward  under  the 
ligament  and  out  through  a  second  incision  just  above  it; 
a  cutf  of  joeritoneum  is  brought  up  between  the  external 
abdominal  ring  and  the  edge  of  the  rectus  and  into  it  is 
sutured  the  end  of  the  vein;  the  opening  through  the 
abdominal  wall  w^as  made  by  splitting  and  is  sutured  open 
to  prevent  constriction  of  the  vein.  Dobbertin  found  that 
the  blood  from  the  vein  did  not  escape  into  the  perito- 
neum; he  claims  that  the  oj)eration  is  simple  and  harm- 
less, and  adds  that  it  may  become  necessary  to  repeat 
the  operation  on  the  other  side  later.  Although  this 
procedure  returns  to  the  blood  by  the  most  direct  route, 
the  fluid  which  originally  came  from  the  blood,  there  are 


sHenschen:     Zentralbl.   f.   Chin,  Jan.    11,  1913. 

^'Dobbertin:      Die    directe    Daurdrainage    des    chronischeii    Ascites    durch    de    ^'ena 
saphena  in  die  Blutbahn,  Arch.  f.  Clin.   Chir.,  1913,  No.  4. 


FILARIASIS  107 

secondary  changes  at  times  in  the  peritoneal  fluid  on  ac- 
count of  which  It  might  be  better  to  return  it  to  the 
systemic  circulation  by  an  indirect  path  or  through  the 
lymphatics. 

De  Lambotte^'  (1905)  of  Antwerp  was  the  first  to  use 
silk  to  drain  the  abdomen;  he  tied  a  large  knot  6.5  cm. 
(2V2  inches)  from  one  end  of  a  thick  silk  thread  54  cm. 
(18  inches)  long,  put  the  knotted  end  in  the  peritoneal 
cavity  and  the  rest  of  the  silk  under  the  skin  of  the 
thigh;  marked  edema  appeared  the  fourth  day  in  the  thigh 
but  soon  ceased  because  the  intraperitoneal  end  became 
embedded.  Of  the  ascites  cases  reported  by  this  method 
the  most  instructive  and  suggestive  in  many  ways  was 
one  of  Handley's.  Until  five  to  seven  months  after  the 
operation  no  proof  was  evident  of  drainage  along  the 
silks  in  the  thigh,  when  the  edema  appeared  simulta- 
neously with  a  crop  of  gummata;  no  specific  treatment 
was  given  until  nine  months  after  the  operation. 

In  1913,  by  a  series  of  experiments,  V-  attempted  to 
show  that  the  relief  of  ascites  after  operations  which  her- 
niate an  abdominal  organ,  or  which  implant  silks  from 
the  peritoneal  cavit}^  to  the  subcutaneous  spaces,  is  prob- 
ably not  from  collateral  circulations  in  the  one  case,  or 
from  capillary  drainage  in  the  other,  but  is  due  to  leak- 
age of  the  fluid  through  the  space  alongside  the  mar- 
supialized  organ  or  the  implanted  silks,  which  are  pre- 
vented from  uniting  to  the  surrounding  tissues  firmly 
enough  to  hold  in  water  under  pressure,  not  only  by 
this  pressure  itself,  but  also  by  the  normal  and  constant 
movements  of  the  abdominal  wall.  The  chronic  ascites 
patient  pays  too  dearly  for  relief  by  tapping  off  large 
quantities  of  fluid,  rich  in  proteins,  salts,  and  the  char- 
acteristic constituents  of  the  tissues  and  fluids  of  the 


"De  Lambotte:     Samaine  med.,   1905,   19. 

^-McDill.  J.  R.:  Chronic  Ascites:  Treatment  and  Drainage  by  Lym|iliangioplasty 
through  a  Trocar  Wound  under  Local  Anesthesia:  An  Experimental  Studv,  Surg., 
Gynec.  and  Obst.,  1913,  xvii,  523. 


108  TROPICAL    SURGERY   AXD    DISEASES 

body  -wliicli  are  necessary  to  metabolism,  if  this  transu- 
date can  be  restored  to  the  circulation  by  a  simple  opera- 
tion. My  experiments  show  that  the  ends  of  three  strands 
of  No.  20  silk,  sewed  together  and  slightly  projecting  into 
the  lower  levels  of  the  peritoneal  cavity,  become  a  perma- 
nent silk-connective-tissue  peg;  that  the  breach  it  makes 
in  the  abdominal  wall  allows  the  escape  of  fluid,  and  that 
the  hernia  and  adhesion  liability  is  nil.  In  tliirty  days 
the  intraperitoneal  end  Avas  found  to  have  become  con- 
verted into  a  connective  tissue  and  silk  peg  covered  with 
a  dense  membrane  making  it  impossil)le  as  a  capillary 
drain;  around  tliis  jieg  the  peritoneum  Avas  puckered  and 
everted  (Fig.  37)  and  not  strongly  attached  to  the  silk. 

The  instruments  can  be  made  from  old  tools  found  in 
any  doctor's  office  (Fig.  38).  The  Kelly  tube  with  trocar 
and  the  Pean  forceps  are  not  essential;  use  any  cannula 
that  will  take  the  "carrier"  Avhen  loaded  with  the  silk. 
The  technic  consists  in  (1)  paracentesis  just  above  the 
pubis  and  5  cm.  (2  inches)  from  the  median  line;  be  sure 
the  cannula  is  in,  because  on  account  of  the  recumbent 
position  of  the  patient  very  little  fluid  will  flow;  (2)  pass 
the  silks  (Fig.  39)  through  the  cannula  until  about  2.5 
cm.  (1  inch)  project  beyond  the  parietal  peritoneum;  hold 
it  exactly  there,  slip  the  cannula  out  over  the  ''carrier" 
and  thrust  each  of  the  three  ends  which  have  been  cut  to 
the  desired  length,  using  the  bodkin  eye  first,  downward 
and  in  three  directions  into  the  subcutaneous  fat;  (3)  re- 
move the  ''carrier"  and  without  disturbing  the  silk  ends 
in  the  peritoneal  cavity,  tuck  in  the  bends  of  the  silks  and 
suture  the  skin  opening  very  snugly.  When  these  special 
instruments  are  not  available,  the  silk  can  be  planted 
through  a  short  incision  under  local  anesthesia,  with  one 
stitch  to  anchor  it  to  the  deep  fascia;  also  after  an  ex- 
13loration,  when  it  is  indicated,  the  silk  can  be  easily  in- 
serted to  one  or  both  sides  of  the  wound  before  closing 
the  abdomen. 


FILARTASTS 


109 


Fig.    37. — The  silk  is   covered  with  a  dense   membrane  and   at  the   angle   with  parietal 
peritoneum  shows  a  marked  ectropion  of  the  peritoneum.      (Author's  collection.) 


Fig.  38. — A,  Sim's  uterine  sound;  B.  same  with  handle  removed,  blunt  end  per- 
forated and  probe  pointed,  making  the  "Bodkin;"  C,  25-cm.  (10-inch)  Emmet's  cotton 
carrier;  D,  No.  14  standard  gauge  catheter;  E,  the  "silk  carrier,"  made  from  C  and  D ; 
F,  trocar  for  the  Kelly  endoscopic  tube;  G,  used  as  cannula;  H,  Pean  forceps. 
(Author's  collection.) 


Fig.  39. — The  three  pieces  of  No.  20  silk  with  aljout  4  cm.  (1^^  inches)  of  their 
ends  stitched  firmly  together  with  fine  silk,  held  in  the  silk  carrier  ready  for  insertion 
through  the  cannula.     (Author's  collection.) 


110  tropical  surgery  and  diseases 

Conclusions 

1.  Ascites  patients  have  an  impaired  vital  resistance, 
deficient  powers  of  repair,  and  do  not  stand  extensive 
operations  well  under  a  general  anesthesia. 

2.  The  operation  is  not  much  more  serious  than  a  simple 
paracentesis  and  other  silks  can  be  inserted  at  any  subse- 
quent tapping  until  there  is  sufficient  drainage;  pressure 
by  intraperitoneal  fluid  is  desirable  after  this  operation 
to  weaken  the  line  of  union  between  the  silk  and  the  sur- 
rounding tissues,  but  if  it  becomes  too  distressing,  a 
tapping  may  be  necessary  to  give  temporary  relief,  on 
which  occasion  more  silks  may  be  inserted:  permanent 
drainage  may  not  become  established  until  two  or  three 
pionths. 

3.  The  permanency  of  any  improvement  will  depend 
upon  the  correction  of  an  intestinal  toxemia  when  pres- 
ent, rest  in  bed  when  indicated,  total  withdrawal  of  alco- 
hol, a  bland  and  almost  salt-free  diet,  and  attention  to 
any  cardiovascularrenal  disturbances.  Several  good 
results  have  been  reported  in  favorable  cases;  that  is,  in 
those  in  which  the  eifusion  was  chronic  and  aseptic. 

Lymph  Varix  and  Lymph  Varicose  Glands 

Although  Ijmiph  varix  and  lymph  varicose  glands  may 
occur  am'^vhere  in  the  body,  the  varix  is  usually  asso- 
ciated with  chylocele  and  lymph  scrotum  and  the  vari- 
cose glands  are  found  in  tlie  groins  and  both  can  occur 
in  the  same  patient  who  may  also  show  a  chyluria. 
The  beginnings  of  these  conditions  are  usually  painless 
and  attention  may  be  first  called  to  them  by  their  size 
or  by  an  inflammatory  attack ;  to  the  superficial  observer, 
the  groin  glands  may  resemble  hernia;  they  are  a  tangle 
of  varicose  Ipiiphatics  usuall}^  connected  with  pelvic  and 
abdominal  vessels;  the  hj^Dodermic  needle  will  show  the 
characteristic  fluid  which  often  contains  filarial  embryos. 


riLARIASIS  111 

If  they  become  very  troublesome,  removal  can  be  recom- 
mended, but  tlie  patient  should  understand  that  a  sepsis 
may  be  fatal,  lymphorrhagia  may  follow  or  other  neigh- 
boring areas  may  become  implicated  and  cause  an  ele- 
phantiasis. 

Hematochyluria 

This  condition  is  due  to  a  rupture  of  a  lymph  varix 
into  any  part  of  the  genitourinary  tract.  It  is  usually 
discovered  accidentally,  although  pain  in  the  back  and 
groins  may  precede  it.  Often  retention  from  blocking 
of  the  meatus  internus  by  a  coagulum  is  the  first  symptom. 
The  diagnosis  is  unmistakable  as  soon  as  the  milky  or 
peach  colored  urine  appears  and  the  microscope  reveals, 
in  a  large  proportion  of  cases,  the  dead  embryos  of  filaria. 
The  chyluria  comes  and  goes  according  to  the  patent  or 
shut  condition  of  the  opening  from  the  varix.  It  is  very 
chronic  and  the  patient  becomes  extremely  anemic  and 
debilitated.  Treatment,  except  that  directed  at  destruc- 
tion of  the  parent  worms  by  arsenical  preparations,  noted 
above,  is  of  no  value.  Wherry  and  McDill  in  Manila  in 
1904  treated  a  Japanese  girl  for  this  disease  by  x-rays 
after  cinchonizing  her  with  quinine ;  the  embryos  disap- 
peared completely  from  the  blood ;  after  recovering  from 
a  moderate  x-ray  burn,  causing  also  a  left  pleurisy,  she 
recovered  and  was  in  perfect  health  four  years  later. 
Wellman  and  Adelung^^  reported  a  success  after  this 
method  but  the  condition  relapsed  later. 

Bilharzia  Hematobia  (Distomum  Hematobium) 

This  is  another  and  frequent  cause  of  hematuria  prin- 
cipally among  the  natives  of  Egypt  and  seems  limited  to 
Africa;  its  most  characteristic  symptom  is  a  variable 
amount  of  pure  blood  at  the  end  of  micturition  caused  by 
the  presence  of  the  parasite  in  the  wall  of  the  bladder; 

"Wellman  and  Adelung:     Jour.  Amer.  Med.  Assn.,  April  23,   1910,  p.    1368, 


112  TROPICAL    SUEOEEY   AXD    DISEASES 

large  numliers  of  tlie  spined  ova  are  always  found  in  the 
urinary  sediment.  It  is  often  complicated  by  filarial  in- 
fection which  may  contribute  chyle  to  the  urine.  The 
transactions  of  the  German  Urological  Congress  of  1912 
cite  records  showing  that  the  old  Egyptians,  1200  B.  C, 
wore  a  sort  of  condom  to  prevent  the  contraction  of  bil- 
harzia  disease.  According  to  all  authors  recovery  is  in- 
frequent and  curative  treatment  is  futile. 

Eobertsoii'-  (19U)  used  Avliat  he  calls  '•tlmno-benzol" 
for  several  months  as  a  bilharzia  toxin  and  reports  that 
even  in  the  worse  cases  all  swmptoms  and  signs  of  the  in- 
fection disappear,  although  an  egg  or  two  may  be  found 
after  prolonged  search  in  some  cases  which  are  appar- 
ently well.  He  noted  that  hemorrhage  ceases,  all  ureteral, 
vesical  and  urethral  jjaiii  vanishes,  and  in  two  or  three 
days  after  treatment  the  ova  come  away  mostly  stained 
black  lint  all  dead,  as  none  of  them  hatched  out:  the 
detritus  of  bilharzia  also  disappears  and  the  exudate  in 
the  urine  passes  away  almost  entirely  on  boiling.  Rob- 
ertson holds  that  the  helminth  toxins  cause  the  head- 
ache, backache,  sweating,  frequent  micturition,  giddi- 
ness, pallor  and  emaciation  and,  that  as  the  remedy  re- 
moves them  all,  "th^Tiio-benzol"  is  toxic  to  the  worms 
themselves.  His  prescription  is  three  grains  of  th^^miol 
in  ninety  grains  of  benzol  every  four  hours  for  three 
or  four  days  and  urotropin  administered  in  the  intervals. 

Ekins^^  tried  this  treatment  on  four  cases  in  Alexan- 
dria; they  were  not  benefited  by  the  drug,  on  the  con- 
trary, he  feels  that  it  may  be  harmful  and  he  found  that 
the  intoxicating  effect,  which  lasted  several  days,  was  a 
great  nuisance  as  the  patients  had  to  be  held  in  their 
beds.  Further  experimentation  may  show  where  the 
teclinic  of  these  two  men  is  at  fault. 


"Robertson,  William:  Thymol-Benzol  in  Bilbarziasis.  Tr.  Soc.  Trop.  Med.  and 
Myg.,  Xov.,  1914,  viii,  Xo.  1. 

i^Ekins,  C.  M.,  Director.  Alexandria  Hospital,  Eg>'pt:  Tr.  Soc.  Trop.  Med.  and 
Hyg.,  June,  1915,  viii.  No.  7. 


FILARIASIS  11^3 

Dracunculus   Medinensis,    Dracontiasis,    Guinea   Worm, 
or  the  Worm  of  Pharaoh,  Etc. 

This  is  one  of  the  most  ancient  and  widespread  of  tropic 
diseases  and  is  also  occasionally  found  in  the  lower  ani- 
mals. It  is  believed  to  have  been  ''the  plague  of  fiery 
serpents"  complained  of  by  the  Israelites  in  the  Desert. 
The  intermediate  hosts  according  to  the  experiments  of 
Feschenko,  confirmed  by  Manson  in  Turkestan,  are  cer- 
tian  fresh  water  cylops ;  the  embryo  nematodes  in  water 
gain  the  interior  of  the  body  cavity  of  the  cyclops  by 
penetrating  its  integument  and  there  undergo  a  meta- 
morphosis similar  to  F.  nocturna  in  the  mosquito.  Leiper 
showed  that  very  dilute  hydrochloric  acid  on  the  infected 
cyclops  releases  the  eml)ryos;  this  is  probably  what  oc- 
curs in  the  gastric  juice  of  the  human  stomach  when  in- 
fected water  is  drunk.  The  female  worm  alone  is  known 
in  the  pathologic  process  in  the  human  host.  The  full 
grown  worm  is  slender,  yellowish  and  round,  averaging 
about  76  cm.  (30  inches)  in  length  and  about  1  mm.  (%o 
inch)  in  diameter.  The  worm  after  she  matures  from  an 
embryo  in  the  connective  tissues  of  the  trunk  or  limbs 
bores  her  way  usually  to  the  leg  below  the  knee,  and 
pierces  the  skin  by  a  more  or  less  intense  inflammatory 
process,  culminating  in  a  localized  swelling  surmounted 
by  a  blister  which  opens  in  a  few  days,  revealing  a  small 
circular  erosion  with  a  small  opening  at  its  center.  Some- 
times the  head  of  the  worm  protrudes  from  the  little 
hole.  By  douching  the  area  with  cold  water  a  clear  or 
milky  fluid  appears,  or  a  fine  translucent  tube,  supposed 
to  be  the  uterus  prolapsed  through  the  mouth,  protrudes 
for  an  inch  or  so,  fills  with  an  opaque  material  and  rup- 
tures ;  this  fluid  contains  millions  of  embryo  worms  about 
Yso  inch  long  and  Kooo  inch  in  diameter.  If  the  bed  of  the 
worm  becomes  infected  by  pyogenic  organisms,  an  ab- 
scess may  result  by  which  the  worm  is  sloughed  off;  if 


114  TROPICAL   SURGERY   AND   DISEASES 

the  process  is  aseptic,  parturition  progresses  by  the  daily 
delivery  of  the  contents  of  a  couple  of  inches  of  the  uterus, 
which  section  shrivels  up  so  that  in  about  a  fortnight  the 
worm  emerges  spontaneously  or  can  be  withdrawn  readily 
and  the  canal  heals.  Sometimes  the  worm  dies  before 
maturity  or  if  mature  may  fail  to  tunnel  through  the 
skin;  in  such  events  an  abscess  follows  an  infection  or 
the  worm  becomes  encysted  as  p,  hard  subcutaneous 
symptomless  cord. 

Unskillful  attempts  at  early  removal  often  rupture  the 
worm ;  the  escape  of  the  young  into  the  subcutaneous  tis- 
sues usually  results  in  a  disastrous  toxic  inflammation 
which  with  sepsis  added  may  cause  extensive  necrosis, 
may  last  for  weeks  and  leave  some  serious  disabilit}^  The 
best  treatment  is  to  keep  the  opening  clean,  douche  the 
parts  with  cold  water,  and  otherwise  let  it  alone,  espe- 
cially if  it  is  near  a  joint;  if  readily  accessible  it  can  be 
excised.  Emily^^  injected  the  body  of  the  worm,  Avhen  it 
protruded,  with  1 :1000  sublimate  solution  and  found  that 
twenty-four  hours  later  extraction  was  usually  easily  ef- 
fected; when  the  worm  is  not  accessible  at  the  opening, 
he  found  that  a  few  drops  of  the  solution  at  several  places 
as  near  it  as  possible  would  kill  it;  then  it  will  be  ab- 
sorbed or  can  be  excised. 

Filaria  Loa  or  "Calabar  Swellings" 

This  infection  is  most  common  in  West  Africa  and  is 
caused  by  filiform  worms  about  30  to  40  mm.  (1%  to  1% 
inch)  long,  the  male  being  25  per  cent  smaller;  both  sexes 
wander  freely  about  in  the  subcutaneous  tissues;  when 
passing  under  thin  skin  and  especially  under  the  conjunc- 
tiva, they  can  be  plainly  seen.  It  is  not  yet  known  just 
what  insect  acts  as  the  intermediate  host.  The  F.  diurna 
is  suspected  as  the  embryo  of  F.  loa  and  as  the  disease 


i^Emily:     Arch,   de  Med.   Nav.,  June,  1874. 


FILARTASIS  115 

seems  to  be  acquired  only  in  ''the  bush"  some  form  of 
biting  flies  will  no  doubt  be  found  to  be  the  intermediate 
host.  The  worm  in  its  subcutaneous  travels  causes  tran- 
sient swellings,  the  ' '  Calabar  swellings, ' '  due  to  discharge 
of  the  embryos,  which  rarely  call  for  treatment  but  when 
it  traverses  the  subconjunctival  tissues  severe  irritation 
may  result;  it  can  be  removed  through  an  incision. 
Emily's  treatment  by  alcohol  injections  for  the  sub- 
cutaneous manifestations  might  be  useful  as  in  guinea 
worm. 


CHAPTER  IX 

SURGICAL  INFECTIONS 

A    FOURTH    STAGE    OF    SYPHILIS     (GANGOSA, 
YAWS,  AND   CHRONIC   ULCERATIONS) 

Gangosa 

Gangosa,  a  Spanish  word  meaning  '^talking  tlirougli 
the  nose,"  most  common  among  the  natives  of  Guam,  is 
a  chronic  destructive  ulceration  beginning  in  the  fauces 
and  extending  to  the  hard  palate,  nose,  and  even  to  the 
face,  neck,  arms,  and  thorax.  This  disease,  thought  for 
a  time  to  be  peculiar  to  the  Marianas,  the  Caroline  and 
the  Marshall  Islands,  is  now  being  discovered  through- 
out the  Tropics  generally.  The  physiognomy  of  some  of 
the  natives  of  the  Philippines  suggest  the  effects  of  the 
disease  in  a  modified  form.  Kerr,^  Odell,"  and  Garrison 
of  the  United  States  Navy,  have  told  the  first  clear  story 
of  gangosa,  a  disease  which  has  never  been  understoood 
and  which  has  resisted  treatment  from  earliest  times  to 
1910.    Senn  referred  to  it  as  "  the  unknown  disease. ' ' 

Julius  Rosenbaum,  of  Berlin,  and  Halle,  in  his  "Ge- 
schichte  der  Lustseuche  im  Alterthume,"  quotes  Dio 
Chrysostom,  of  the  second  century,  who  scores  the  in- 
habitants of  the  City  of  Tarsus  for  a  widespread  afflic- 
tion which  he  attributed  to  their  notorious  sexual  perver- 
sions and  which  seems  to  have  been  a  disease  similar  to 
what  we  call  gangosa.  Referring  to  the  ''snoring  and 
snorting"  of  the  people  of  Tarsus  he  says:  "However,  not 
primary  affections  of  the  posteriors  were  the  punishment 
of  the  Cinaedus,  but  secondarv  ones  of  the  mouth  and 


^Kerr,  W.  M. :     Gangosa.  U.   S.  Nav.  Med.  Bull.,  April,   1913. 

-Odell,  H.  E.,  Surgeon,  tj.   S.  Navy:     Personal  communication,  Nov.,   1911. 

116 


GANGOSA  117 

throat.  First  and  foremost  was  the  hoarseness  of  the 
voice,  to  which  ]\Iartial  alludes,  Avlien  he  makes  the 
champion  of  the  baths,  the  Cinaedus  Charinus,  speak 
with  a  weak,  hoarse  voice.  It  is  surely  worth  mentioning 
and  it  is  a  thing  no  one  can  deny.  I  mean  the  noteworthy 
fact  that  a  disease  has  attacked  so  man}^  in  this  city.  I 
can  not,  by  heaven,  express  myself  more  clearly  with 
decency.  The  grossest  ignominy  is  brought  down  upon 
their  native  city  by  these  sleepers  by  day,  the  drunken, 
the  overfed,  and  such  as  have  lain  ill,  and  they  ought,  I 
say,  to  have  been  expelled  from  your  borders  as  has  been 
their  fate  everywhere  else.  For  it  is  not  now  and  then, 
or  here  and  there,  they  are  met  with,  but  at  all  times  and 
in  all  places  in  the  city  occasion  may  be  found  to  threaten, 
scorn  and  deride  them  for  these  signs  and  sounds  of 
shamelessness  and  lewdness  the  most  scandalous.  If  a 
man  passes  in  front  of  a  house  in  which  he  catches  the 
sound,  he  says, '  Of  a  surety  there  is  a  1)rot]iel  there. '  Now 
what  shall  be  said  of  a  city  in  which  nothing  but  this  tone 
of  voice  prevails  universally  so  that  no  exception  can  be 
made  of  time  or  place  whatever!  What  if,  further,  all 
men  walk  in  this  city  with  skirts  upraised  as  if  wading 
in  a  quagmire  ?  Tell  me  what  is  the  reason  others  nick- 
name you  'hawks?'  Well  then!  suppose  a  stranger  from 
a  distance  judges  from  your  voices  what  kind  of  men  you 
are,  what  it  is  you  do?  You  are  not  fit,  I  tell  you,  to  be 
neatherds  or  shepherds.  I  wonder  anyone  would  take  you 
for  descendents  of  the  Argives,  as  you  profess  to  be,  or 
indeed  for  Greeks  at  all, — you  who  outdo  the  Phoenicians 
in  lubricity.  At  any  rate  I  do  think  it  would  behoove  a 
man  of  any  morality  in  such  a  city  to  close  his  ears 
with  wax,  far  more  than  if  he  were  sailing  past  the 
Syrens'  shore.  There  he  would  run  the  risk  of  death, 
but  here  of  foulest  licence,  of  violation,  of  the  vilest  seduc- 
tion. Once  Ionic  harmony  was  in  vogue,  or  Doric,  or  yet 
the  Phrygian  and  Lydian,  now  it  is  the  music  of  Aradus 


118 


TROPICAL   SURGERY   AlTD   DISEASES 


o 


GANGOSA 


119 


gz 

>'-/i 


120 


TROPICAL    SURGERY   AND   DISEASES 


?S 


GANGOSA 


121 


and  the  Phoenician  modes  that  please  yon.  You  love  this 
rhythm  par  excellence  as  others  do  the  Spondaic.  AYas 
over  a  race  of  men  that  were  good  musicianers — through 
the  nose?    Know  now  tluit  tlie  gods  in  their  ano-er  have 


Fig.    43. — Gangosa   lesions.      Guam.      Noguchi    negative.      Lesions    closed   under   mi.xed 
treatment.      (U.    S.   Navy  Med.   Bulletin.) 


played  havoc  with  the  noses  of  most  of  your  fellow  citi- 
zens, and  that  is  why  they  have  this  voice  of  their  own. 
But  I  sa}^  this  thing  is  the  mark  of  the  most  infamous 
lewdness,  of  the  most  infamous  madness,  of  contempt  for 
all  decency  and  a  proof  of  the  fact  that  there  is  no  more 


122 


TROPICAL    SURGERY    AND    DISEASES 


any  single  thing  held  to  be  disgraceful.     Their  speech, 
their  look,  their  gait  proclaim  it." 

Gangosa  is  not  fatal;  the  ulcerations  are  of  the  naso- 
pharynx, derm  and  hypoderm;  no  visceral  lesions  are 
found;  the  upper  lip  is  usually  spared;  the  tongue  and 
floor  of  the  mouth  are  never  affected.  (Figs.  40,  41,  and 
42).    The  skin  ulcerations  which  occur  anywhere  except 


Fig.    4-1. — Extensive   gangosa   mutilation   in   a   Filipina.      (U.    S.   Navy  Med.    Bulletin.) 

over  the  abdomen  show  two  types;  one,  developing  as  a 
small  nodule,  or  patch  of  nodules,  softens  and  discharges 
at  the  apex  through  a  small  opening ;  the  second  and  most 
common  tjj)e  has  a  sharply  defined,  raised,  cyanotic  mar- 
gin with  a  necrotic  base,  a  seropurulent  discharge  and 
may  be  very  extensive,  is  not  painful,  heals  very  slowly, 
recurs  often,  and  may  be  very  disfiguring.  The  gumma- 
like  lesions  of  bone,  tendons,  and  subcutaneous  tissues  are 


GANGOSA 


Fig.  45. — Gangosa.  Age  17.  Frambesia  when  5  years.  Ulcerations  ten  years; 
healed  under  mixed  treatment.  Complement-fixation  test  (Fniery)  positive.  Noguchi 
positive.      (Kerr:     U.   S.  Navy  Med.   Bulletin.) 


124  TEOPICAL  SURGERY  AXD  DISEASES 

not  so  common  and  occur  usually  in  tlie  leg  and  leg  bones. 
(Figs.  43,  44,  and  45.) 

There  is  still  considerable  to  be  done  on  the  pathology. 
Gangosa  has  always  been  a  puzzling  disease  until  cleared 
up  through  therapeutic  and  serologic  tests  by  the  medical 
officers  of  the  United  States  Xavy.  Early  in  1910,  Odell 
instituted  the  treatment  which  has  eradicated  the  active 
manifestations  of  the  disease  and  the  secret  of  his  suc- 
cess lay  in  enforcement  by  military  order  of  antisjqohilitic 
therapy;  338  cases  were  found  among  a  population  of 
11,000;  under  a  mixed  treatment  all  active  signs  of  the 
lesions  ceased  in  about  eight  months  and  the  few  relapses 
were  found  to  have  evaded  taking  the  medicine;  this 
therapy  was  persisted  in  for  two  years  when  it  was  sus- 
pended for  six  months  to  observe  tendencies  to  relapse. 
Salvarsan  was  received  about  the  middle  of  1912  and  its 
effect  on  the  new  cases  was  very  striking;  it  is  now  the 
prime  factor  in  controlling  the  disease  although  it  must 
be  supplemented  by  a  prolonged  course  of  mixed  treat- 
ment. Xo  laboratory  technic  has  revealed  the  presence 
of  a  treponema  of  any  description  and  no  cases  of  syphilis 
have  ever  been  found  to  originate  in  Guam.  Garrison 
says  there  are  no  tabes,  paresis,  hydrocephalus  or  syphil- 
itic abortions  in  Guam  and  that  in  150  autopsies  he  saw 
but  two  or  three  gummatous  livers;  but  as  the  disease 
yields  magically  to  antiluetic  treatment,  looks  like  noth- 
ing but  syiohilis,  nine  cases  out  of  ten  being  near  relatives 
to  other  typical  cases,  and  as  the  scars  are  characteristic, 
it  is  perhaps  a  fourth  stage  of  syphilis.  After  one  3^ear 
of  treatment,  one  hundred  cases  showed  a  positive  Was- 
sermann  test  in  82  per  cent,  slightl}^  positive  in  3  per  cent 
and  negative  in  15  per  cent.  Eeactions  on  brothers  and 
sisters  were  also  positive  although  these  blood  relatives 
showed  no  gangosa;  83  |)er  cent  of  315  cases  gave  a  posi- 
tive history  of  yaws  prior  to  the  first  symptom  of  the 
gangosa. 


GANGOSA  125 

Frambesia,  or  Yaws 

Frambesia  or  }' aws  is  found  everywhere  under  various 
names  throughout  tlie  tropical  world.  Although  very, 
debilitating  and  rej)ulsive  in  appearance,  the  disease  is 
seldom  fatal  and  is  regarded  by  the  races  among  whom 
it  is  prevalent  as  an  inevitable  disease  of  childhood.  It 
also  appears  in  a  late  or  tertiary  form  among  adults, 
usually  of  the  face,  causing  in  some  cases  flattening  of 
the  nose;  another  very  chronic  form  is  found  on  the 
soles  of  the  feet  where  it  protrudes  as  a  round  flat  painful 
growth  through  the  thickened  skin.  In  Guam  after  ex- 
aminations of  2429  normal  natives  it  was  found  that  74 
per  cent  had  contracted  the  disease,  generally  during 
childhood.    (Figs.  46,  47,  and  48.) 

It  has  an  incubation  stage  of  two  to  twenty  weeks ;  the 
eruption  is  preceded  by  an  initial  fever  of  variable  in- 
tensit}^  of  about  one  week  and  during  its  decline  the 
eruption  appears,  preceded  by  a  patchy  white  desquama- 
tion, in  which  minute  papules  push  up  through  the  skin 
and  acquire  a  cheesy,  yellow  summit ;  the  typical  yaw  may 
■grow  in  two  weeks  to  any  size  up  to  3  cm.  (I14  inches) 
in  diameter,  as  a  rounded  excresence,  capped  and  en- 
closed by  the  yellow  material,  which  dries  and  becomes 
a  firmly  adherent,  dark  or  black  crust;  it  requires  some 
force  to  remove  the  crust,  when  a  smooth,  rounded,  red, 
painless  swelling  is  seen  extending  %  to  %  inch  above 
the  surface  of  the  skin,  somewhat  resembling  a  rasp- 
berry from  which  it  has  its  name ;  the  crust  soon  re-forms ; 
it  remains  stationary  several  weeks  and  then  shrinks  and 
falls  off.  Several  yaws,  especially  about  the  mouth  and 
anus,  may  coalesce,  leaving  an  ulcerated  and  fissured 
base;  according  to  the  nature  of  the  mixed  infection,  ul- 
cerations of  various  degrees  occur  and  may  persist  for 
years;  healing  of  these  surfaces  often  leaves  marked 
cicatricial  deformity;  recurrences  are  not  uncommon.    In 


126 


TROPICAL    SUEGEEY   AXD    DISEASES 


r 


Fig.   46.— Yaws  in   Samoa.      (U.   S.   Navy  Med.   Bulletin.) 


GANGOSA. 


127 


over  90  per  cent  the  Treponema  pertenue  was  demon- 
strated and  all  cases  gave  positive  serum  and  Xoguchi 
reactions  except  in  the  late  or  tertiarj'  cases.  No  syphilis 
has  even  been  recorded  as  contracted  either  in  Guam  or 
Samoa. 

The  treatment  hj  salvarsan,  injected  into   the  mus- 


Fig.   47. — Yaws  in    granddaughter.      Taytay,   Rizal   Province,    Luzon,   P.   I.,   May,    1909. 
(Philippine  Journal   of  Science.) 

cles  of  the  Imttoeks,  was  followed  hy  a  cure  in  eight  to 
ten  days  in  all  cases  that  could  he  controlled;  the  only 
delay  in  healing  was  due  to  mixed  pyogenic  infections; 
relapses  occurred  which  also  healed  promptl}'  after  larger 
doses  of  salvarsan. 


128 


TROPICAL    SURGERY    AND    DISEASES 


Dr.  Knrien,  of  Ce^^lon,  (Report  to  Colonial  Office,  Aug- 
ust 27,  1916)  has  treated  over  3,000  cases  of  yaws  by 
salvarsan,  arsenobenzol  and  kliarsivan  and  found  tliem 
almost  equally  effective  in  curing  tlie  disease  in  from 
three  days  to  three  weeks. 

The  diseases  of  protozoal  origin  referred  to  by  Cas- 
tellani,  are  yaws,  kala-azar,  oriental  sore,  and  relapsing 


Fig.   48. 


-Yaws   in   grandfather.      Taytay,    Rizal    Province,   Ivuzon,   P.    I.,    1909. 
(Philippine  Journal  of   Science.) 


fever.  In  yaws,  on  Castellani's  experience  tartar  emetic 
gives  better  results  when  combined  with  other  drugs,  es- 
pecially potassium  iodide.  Although  salvarsan  and  neo- 
salvarsan  are  without  doubt  the  specific  drugs  for  yaws, 
it  is  often  difficult  to  arrange  for  the  administration  of 
intravenous  injections  in  out  of  the  way  districts  and 


*The  Treatment   of   Certain  Diseases  of  Protozoal  Origin  by  Tartar  Emetic,   Alone 
and  in   Combination,  British  Medical  Journal,  Oct.   21,    1916,   pp.    552-553. 


GANGOSA  129 

also  many  patients  refnse  to  submit  to  any  form  of  in- 
jection. For  these  and  otlier  reasons  an  internal  treat- 
ment by  easily  obtainable  drugs  is  much  to  be  desired 
and  Castellani  gives  a  prescription  which  has  given  ex- 
cellent results  in  Ceylon. 

He  devised  his  "yaws  mixture"  containing  tartar 
emetic,  salicylate  of  soda,  potassium  iodide  and  sodium 
bicarbonate.  The  sodium  salicylate  "seems  to  hasten 
the  disappearance  of  the  thick  yellow  crusts."  The 
sodium  bicarbonate  decreases  the  emetic  properties  of 
the  mixture.  At  the  same  time  it  makes  it  cloudy  but, 
through  the  intervention  of  the  editor  of  the  British 
Medical  Journal,  successful  attempts  have  been  made  to 
obviate  this.  The  result  is  the  modified  formula  given 
below : 


Tartar  emetic 

gi'-  .1 

Sod.  bicarb. 

gr.  XV 

Sod.  salicylate 

gr.  X 

Potass,  iodide 

dr.  j 

Glycerine 

dr.  ij 

Or   syrup 

dr.  j 

Or  sod.   tartarate 

gr.  X 

Aquae 

ad. 

oz.  j 

Castellani  thinks  that  glycerine  gives  the  clearest  mix- 
ture. It  is  given  diluted  in  water  three  times  a  da}^ ;  half 
doses  to  Europeans.  The  mixture  Avas  given  for  ten 
to  fifteen  days,  then  five  to  ten  days'  rest;" then  another 
course  for  another  five  or  ten  or  fifteen  days,  and  sat- 
isfactory results  were  obtained  in  fairly  recent  cases  in 
which  the  disease  had  started  three  to  twelve  months 
previously. 

Castellani  has  recently  treated  four  cases  of  infan- 
tile kala-azar  in  Corfu.  Three  cases  recovered.  They 
were  treated  by  tartar  emetic  in  intravenous  injections 
(1  per  cent  tartar  emetic  in  sterilized  normal  saline),  in 


130  TROPICAL    SURGERY   AKD    DISEASES 

intramuscular  injections,  by  the  mouth,  and  by  combi- 
nations of  these  methods.  The  intramuscular  method  is 
very  convenient  in  children.  To  avoid  the  ]Dain  carbolic 
acid  is  added  according  to  the  following  formula : 


Tartar  emetic 

gr.  Tiij 

Ac.  carbol. 

Til  X 

Glycerine 

dr.  iij 

Aq.   dest. 

ad.  oz.  j 

Half  to  1  c.c.  every  other  day  in  the  gluteal  regions 
by  intramuscular  injection.  The  addition  of  gr.  1/3  sod. 
bicarb,  makes  the  mixture  slightly  alkaline.  Martindale's 
antimonium  oxide  preioaration  is  considered  less  good. 

The  formula  for  oral  administration  is  as  follows : 


Tartar  emetic 

gr. 

V 

Sod.  bicarb. 

gr. 

XXX 

Glycerine 

oz. 

j 

Aq.   chlorof. 

oz. 

j 

Aquse 

ad.  oz. 

iij 

(dr.  j  to  dr.  jj  in  water  t.  d.) 

In  adults  the  dose  can  be  doubled. 

A  case  of  oriental  sore  was  rapidly  cured  Iw  twelve 
intramuscular  injections  and  the  tartar  emetic  mixture. 

Tartar  emetic  has  been  used  in  17  cases  of  relapsing 
fever  in  Macedonia  and  Corfu,  Imt  in  this  disease  it  is 
less  effective  than  salvarsan;  in  a  large  percentage  of 
cases  it  appears  to  prevent  relapses.  Intravenous  in- 
jections give  the  best  result. 

The  conclusion  is  that  tartar  emetic  can  be  considered 
a  specific  in  esiDundia,  granuloma  inguinale,  and  leish- 
maniosis,  that  it  is  efficacious  in  yaws  and  seems  to  have 
a  beneficial  action  also  in  relaiDsing  fever. 

Chronic  Ulcerations 

The  etiology  of  these  conditions,  so  common  among 
the  natives  of  the  ecpiatorial  belt,  is  gradually  becoming 
better  imderstood  as  laboratory  methods  are  introduced. 


GANGOSA 


131 


The  chronic  ulcers  in  Guam  and  Samoa  brought  to  light 
the  fact  that  the  majority  of  the  cases  like  gangosa  and 
fi-ambesia  show  positive  reactions  to  the  Wassermann 
and  Noguchi  tests,  respond  to  salvarsan  and  other  anti- 
luetic  treatment  and  probably  have  the  Treponema  pal- 
lidum or  pertenue  as  the  etiologic  factor.  Figs.  49,  50, 
and  51.)  Eggers'^  (1914),  in  a  preliminary  report,  on 
the  spirochetal  infection  of  leg  ulcers  in  China  found 
115  smears  containing  spirochetes  out  of  1,500  collected 


Fig.    49. — Gristly    healing    of    tropical    phagedenic    ulceration.      Wassermann    positive. 
Filipino.      (Butler:     U.    S.   Navy  Bulletin.) 

from  all  over  China,  and  concluded  that  at  least  one 
of  the  six  types  of  bacilli  found  is  of  clinical  significance ; 
the  others  are  doubtful  and  no  constant  relationship)  can 
be  shoAvn  between  the  types  of  bacilli  and  the  spiro- 
chetes. The  central  part  of  China  seemed  least  involved, 
but  3,000  specimens  are  being  collected  for  a  future  re- 

^IJggers,    H.    E. :      On    the    Spirochetal    Infection    of    Ulcers    in    China,    China    Med. 
Jour.,  Nov.,  1914. 


132 


TROPICAL    SUEGEEY   AXD    DISEASES 


Fig.    50.— Syphilitic   ulcerations   in   Filipino.      (Butler:      U.    S.    Navy   Med.    Bulletin.) 


GAXGOSA 


133 


Fig.   51. — "Tropical  ulceration."     Bone  exposed.      Positive   Wassermann.      Filipina. 
Probably    gangosa.      (Butler:      U.    S.    Xavy    Med.    Bulletin.) 

port.  Eeed,  of  Cliangslia,  Cliina,  ol)served  little  tertiary 
syphilis,  but  saw  the  primary  and  secondary  forms  often 
and  suspects  that  the  Treponema  there  must  be  of  a  dif- 
ferent strain  from  the  usual. 


134 


TROPICAL    SURGERY    AND    DISEASES 

LEPROSY 


In  the  absence  of  successful  medical  or  specific  treat- 
ment, the  operative  surgery  of  leprosy  and  its  complica- 
tions has  not  received  the  attention  in  standard  works 
tliat  it  should  and,  except  in  a  few  leper  colonies,  the 


'*-,'*«»• 


*.   * 


.«-. 


#■ 


Fig.     52. — Early     nodular    leprosy.       Infiltration     of    ear.       (Unpublished     photo     from 
Hawaii — Courtesy  of  Moses  Clegg.) 

radical  methods  of  the  surgeon  which  are  the  main  agents 
in  the  treatment  are  not  employed  to  the  extent  demanded 
by  this  class  of  sufferers. 

Leprosy  was  described  in  the  Bible  by  Moses  in  1500 
B.  C,  and  his  instructions  for  segregation  were  of  divine 
origin,  but  Egyptian  records   of  leprosy  antedate  the 


LEPROSY 


135 


Bible  thousands  of  years.  In  spite  of  all  tliat  has  been 
done,  the  disease  in  some  localities  is  spreading  rapidly. 
Morrow^  states  that  ''In  Basutoland,  in  1895,  the  total 
number  of  lepers  was  148,  and  at  the  close  of  1912  there 
were  700."     This  increase  is  probably  not  entirely  due 


Fig.    S3. — Advanced   nodular,  leprosy.      (Unpublished   photo    from   Hawaii — Courtesy    of 

Moses  Clegg.) 

to  new  eases  as  our  experience  in  the  Philippines  showed 
that  the  more  efficient  the  inspection  the  more  cases  of 
leprosy  were  found.  The  last  reports  showed  that  there 
were  about   three  million  lepers  in  the  world   and   of 


^Morrow:     South  African  Med.  Rec,  June  28,   1913. 


136 


TEOPICAL    SURGERY    AXD    DISEASES 


these  only  169  were  of  official  record  in  the  United  States 
up  to  1914;  but  there  are  twenty-five  hundred  lepers  in 
the  United  States  and  no  leprosarium. 

This  chronic  condition  is  due  to  an  infection  with  the 
bacillus  lepra?  discovered  by  Hansen  in  1871   and  first 


Fig.  54. — Pure  nerve  leprosy.     Atrophy  and  contraction  of  hands.      (Unpublished  photo 
from  Hawaii — Courtesy  of  Moses  Clegg.) 

successfully  cultivated  by  Moses  Clegg  in  Manila  in 
1909.  The  bacilli  are  found  only  in  the  nodular  and 
mixed  types;  never  in  the  anesthetic  form.  Although  it 
can  not  be  proved  by  present  methods,  the  contagious- 
ness of  leprosy  is  admitted  by  all  observers.     The  field 


LEPROSY 


137 


In  gon- 


for  investigation  of  leprosy  is  still  wide  open, 
eral,  animal  inoculations  with  leprous  material  have 
been  negative.  The  great  majority  of  leprologists  hold 
that  leprosy  has  not  been  produced  in  laboratory  ani- 


Fig.    55. — Nerve   leprosy.      Infiltrrilion   of    lianJ.      Facial   paralysis.      (,1'npuljlislied   photo 
from    Hawaii — Courtesy   of   Moses   Clegg.) 

mals ;  over  seventy  unsuccessful  attempts  have  been  made 
to  inoculate  leprous  material  in  man.  The  Barbadian 
leper  might  be  an  exceptional  subject  for  study  because 
their  pigs,  fed  on  old  dressings,  developed  a  peculiar  dis- 
ease with  skin  lesions  and  at  the  same  time  the  rodents 


138 


TROPICAL    SUEGEEY    AND    DISEASES 


•developed  tlie   rat  leprosy.     (Figs.  52,   53,   54,   55,   56, 
and  57.) 

Forty  per  cent  of  the  children  of  lepers  die  during  their 
first  3"ear  of  life  but  only  a  small  percentage  of  the  sur- 
vivors develop  the  disease  and  then  only  after  an  ex- 
posure of  three  to  fifteen  years;  the  average  exposure 
necessary  is  five  years.  Although  an  immense  amount 
of  work  has  been  and  is  being  done,  serodiagnosis  and 


Fig.  56. — Nerve  leprosy.     Plantar  pedis  ulcer.     Small  toe  removed  for  necrosis. 
(Unpublished   photo   from   Hawaii — Courtesy   of   Moses    Clegg.) 

immunity  tests  are  discouraging  and  so  far  are  incon- 
clusive. Lepers  are  subject  to  all  other  ills  of  the  flesh, 
but  their  sedentary  life  protects  them  from  the  usual 
amount  of  traumas  and  from  the  penalties  of  strenuous 
and  high  living.  The  Wassermann  reaction  is  positive  in 
a  considerable  number  of  cases  and  the  syphilis  which  is 
at  times  confused  with  the  leprotic  state  does  not  seem 
in  any  Avay  to  be  modified  by  the  leprosy  and  is  readily 


LEPKOSY 


139 


cleared  up  by  antiluetic  treatment.  Tuberculosis  is  an- 
other common  complication  of  leprosy  and  in  some  colo- 
nies 50  per  cent  of  the  inmates  are  tuberculous.     The 


Fig.    57. — Macular   leprosy.      Ringworm   form    of   infection.      (Unpublished   photo    from 
Hawaii — Courtesy  of  Moses  Clegg.) 


incidence  of  cancer  and  all  other  affections,  except  eye 
lesions  and  ulcers,  seems  to  be  rather  low. 


140  TROPICAL    SUEGERY    AXD    DISEASES 

The  best  general  treatment  is  segregation  on  a  fertile 
island  situated  in  a  warm  and  equable  climate,  in  com- 
munities arranged  with  special  regard  to  municipal  and 
personal  hygiene  and  to  social  Avelfare  conditions.  The 
nodular  and  anesthetic  lepers  should  be  separated  to  pre- 
vent the  development  of  the  mixed  type  which  is  rapidly 
fatal;  the  usual  antituberculosis  measures  are  also  in- 
dicated. Of  alleviating  drugs  the  ancient  Chinese  remedy, 
chaulnioogra  oil,  is  the  only  one  that  has  retained  an}' 
reputation.  The  most  extensive  modern  application  of 
this  remedy  has  been  made  by  Heiser^  whose  experiments 
are  very  encouraging  especially  in  arresting  the  disease. 

Heiser's  formula  is,  chaulnioogra  oil,  60  c.c;  camphor- 
ated oil,  60  c.c,  and  resorcin,  4  gm.,  sterilized,  filtered,  and 
injected  under  the  skin  of  the  arms  or  legs.  Injections 
were  begun  with  one  cubic  centimeter  weekly  and  after 
tliree  weeks  the  weekly  dose  was  gradually  raised  to  3 
c.c,  or  more  as  tolerated.  The  reaction  begins  a  few 
liours  after  injection  and  lasts  till  the  next  day;  it  follows 
the  first  injection  only  and  consists  of  slight  headache, 
malaise  and  some  nausea.  Weekly  injections  have  been 
keijt  up  for  nine  months.  AVithin  four  weeks  all  patients 
show  marked  improvement.  The  tuberculous  forms  seem 
to  respond  to  the  treatment  l)etter  than  the  anesthetic 
forms. 

The  oil  is  used  hypodermically  and  the  prolonged  hot 
baths  as  employed  at  the  Louisiana  Leper  Home  are  made 
a  part  of  the  treatment. 

The  Surgery  of  Leprosy 

Preoperative  Care  and  Anesthesia. — Owing  to  the  re- 
duced resistance  and  low  nutrition  of  the  skin  and  other 
tissues,  strong  antiseptics  are  particularly  contraindi- 
cated.  The  skin  around  an  ulcer  is  usually  very  unhealthy 
and  harbors  i3athogenic  organisms  in  abundance.     Dr. 


^Heiser,  Mctor  G.:     Am.  Jour.  Trop.  Dis.,  Nov.,  1914. 


LEPEOSY  141 

Sandes,''  of  Cape  Town,  South  Africa,  who  has  done  splen- 
did work  in  the  surgery  of  lepers,  prepares  for  operation 
in  the  following  manner  which  would  be  hard  to  improve 
upon. 

"The  previous  day  the  patient  was  bathed;  the  particu- 
lar site  well,  but  gently,  washed  with  soap  and  Avater, 
shaved  and  swabbed  with  alcohol.  A  one  per  cent  alco- 
holic solution  of  iodine  was  then  applied,  and  the  part 
wrapped  up  in  an  aseptic  cloth.  On  being  placed  on  the 
table,  the  area  was  swathed  with  alcohol  and  a  second 
application  of  the  iodine  solution.  A  large  cup  of  bovril 
or  beef  tea  one  hour  before  operation  seemed  to  have. an 
excellent  and  stimulating  effect  in  tiding  the  patient  over 
the  subsequent  period  of  stress  and  exposure." 

Anesthetics. — As  a  rule  even  no  local  anesthetic  is  nec- 
essary in  the  insensitive  areas,  so  common  in  lepers,  espe- 
cially if  the  confidence  of  the  patient  is  secured  and  sur- 
gical violence  is  avoided;  when  pain  is  caused  during  an 
operation,  novocaine  is  indicated.  Special  caution  is  re- 
quired during  general  anesthesia  on  account  of  the  feeble 
heart  and  the  general  tissue  saturation  with  waste  prod- 
ucts, germs,  and  toxins.  The  drop  method  with  ether  is 
best  but  for  all  abdominal  and  work  lower  down  Sa'ndes 
relies  upon  spinal  anesthesia  which  he  has  found  safer 
and  preferable  to  ether. 

The  following  brief  report  by  AY.  J.  Goodhue  of  325 
operations,  x^erformed  in  1913  at  the  Hawaii  Settlement 
of  700  lepers  at  Molokai,  is  ample  proof  that  surgery  is 
the  main  factor  at  present  in  the  therapy  of  leprosy. 

Leg-  amputations   5 

Arm  amiiutations    3 

Eesection   of  bone  for  osteomyelitic   bone  necrosis 120 

Eadical  surgical  interference  for  cure  of  plantar-pedis  ulcer.  .  64 

Excision  of  axillary  glands  for  axillary  adenitis 12 

Excision  of  cervical  glands  for  ceivical  adenitis 4 


"Sandes,  T.  Lindsay:     South  African  Med.  Rec,  June  28,   1913. 


142  TROPICAL  SURGERY  AND  DISEASES 

Excision  of  inguinal  glands  for  inguinal  adenitis 8 

Excision  of  femoral  glands  for  femoral  adenitis 2 

Excision  of  mammary  glands  for  mammary  adenitis 2 

Excision  of  submaxillary  glands  for  submaxillary  adenitis ....  3 

Leproniatous  infiltration  ulnar  nerve 8 

Nerve  stretching  of  ulnar  for  acute  ulna-algia 3 

Nerve  stretching  of  ulnar  for  digital  flexion 5 

Plastic  operation  for  labial  stenosis 2 

Plastic  operation  for  inferior  labial  paralysis 1 

Tracheotomy  cases  for  laryngeal  stenosis  and  imminent  stran- 
gulation     12 

Tracheotomy  cases  for  relief  of  complete  ajjlionia 3 

Tonsillotomy 7 

Uvulotomy 3 

Operation  for   cure   of  pterygium   of   one   or    both   eyes  with 

Paquelin  cautery   58 

Total  number  of  glandular  cases 28 

Total 325 

Based  on  observations  at  this  clinic,  the  great  value  of 
tracheotomy  should  be  emphasized.  Sandes  does  not  put 
it  any  too  strongly  when  he  says:  ''Tracheotomy  under 
local  anaesthesia  through  the  upper  four  rings  of  the 
trachea  gives  instant  relief.  It  is  not  a  brief  postpone- 
ment, but  a  satisfactory  and  permanent  reprieve  as  far 
as  the  larynx  is  concerned.  The  lowering  shadows  of 
mors  suhita  are  dissipated.  In  a  day's  time  the  smiling 
features  of  a  refreshed  and  grateful  patient  tell  their 
own  tale."  It  is  done  by  Goodhue  mth  or  without  an 
anesthetic.  Often  after  a  few  weeks  the  tube  may  be 
removed,  the  lar^mgeal  condition  having  subsided. 

Ulcers  are  the  most  common  affliction  of  lepers;  the 
majority  of  them  are  due  to  even  the  slightest  of  injuries, 
especially  burns,  and  are  not  leprous  in  their  pathology. 
They  are  treated  as  any  other  ulcer  in  a  nonleprous  pa- 
tient and  the  results  are  as  gratifying;  skin-grafting  is 
very  successful  after  the  surface  has  been  suitably  pre- 
pared; a  warning  for  the  treatment  of  atrophic  ulcer  is 
that  if  the  local  circulation  is  embarrassed  by  even  slight 
constriction  or  pressure  it  will  never  improve. 


SURGICAL    TUBERCULOSIS  143 

Osteomyelitis  and  necrosis  particularly  of  the  hands 
and  feet  furnish  by  far  the  largest  number  of  operations 
in  lepers  and  recurrences  are  frequent.  In  some  cases  all 
that  was  left  of  the  fingers  was  a  row  of  finger  nails  rest- 
ing on  the  metacarpal  bones,  the  characteristic  adactylate 
stump  of  leprosy.  This  bone  destruction  is  due  as  much 
to  trophic  disturbances  shown  by  decalcification  and 
osteoporosis  as  to  microbic  causes  which  are  often 
secondar}?-  invaders.  The  treatment  should  be  radical 
removal  of  an  affected  bone  or  its  shaft  to  prevent  recur- 
rences and  sinus  formation. 

Neurologic  Operations  for  the  results  of  deposits  in 
nerve  trunks  causing  contractures  differ  not  at  all  from 
these  procedures  elsewhere.  Interference  with  the  con- 
tinuity of  the  nerve  itself  is  followed  by  bad  results. 
Nerve  anastomosis  to  arrest  changes  has  not  been  tried  in 
suitable  early  cases,  but  on  terminal  cases  Sandes  claims 
it  will  restore  a  considerable  amount  of  sensation,  appre- 
ciation of  pain,  and  tactile  sense. 

The  Eye  Complications  are  a  most  serious  feature  of 
lepros}^;  in  the  first  decade  90  per  cent  are  affected  and 
the  treatment  has  been  so  unsatisfactory  that  an  ophthal- 
mologist should  be  stationed  at  every  leper  colony. 
Opacities  from  corneal  ulceration  following  ectropion, 
due  to  paresis  of  the  orbicularis,  are  very  common. 
Chronic  iridocyclitis  is  said  to  be  the  most  serious  lesion; 
with  occluded  pupil  and  secondary  cataract  it  results  in 
total  blindness  in  many,  and  all  become  more  or  less 
blind.  The  retina  and  the  optic  nerve  usually  escape 
damage  until  very  late  and  then  it  is  not  usually  due  to 
the  lepra  bacillus. 

SURGICAL  TUBERCULOSIS 

In  the  Philippines,  tuberculosis  affects  probably  the 
entire  population  and  about  2  per  cent  of  the  population 
have  the  disease  in  an  advanced  form;  from  reports  it  is 


144  TROPICAL    SURGERY   AXD    DISEASES 

probable  that  this  rate  also  obtains  in  the  crowded  sec- 
tions of  India  and  China.  It  is  veiy  rare  in  cattle;  is 
practically  unknown  among  the  carabaos  or  water  buffalo, 
pigs  and  goats;  but  surgical  tuberculosis  among  the  na- 
tives is  not  uncommon.  In  10,000  surgical  cases  in  Manila 
I  found  about  500  cases  of  bone,  joint,  and  glandular 
tuberculosis,  mostly  glandular.  There  is  nothing  to  dis- 
tinguish these  cases  clinically  from  those  of  temperate 
zones. 

DISEASES  OF  THE  SKIN 

Dermal    Leishmanioses    (Oriental    Sore,    Aleppo    Boil, 
Biskra  Button,  Delhi  Sore,  Fly  Bite,  Etc.) 

This  condition  has  as  mam^  names  as  districts  in  which 
it  occurs.  It  is  widely  scattered  throughout  both  tropic 
and  sulitropic  countries  and  elsewhere  wherever  labora- 
tories for  medical  research  are  established.  Darling^  dis- 
covered two  autochthonous  cases  of  Oriental  sore  in  the 
Canal  Zone  in  1910  and  gives  a  complete  history  of  the 
disease  to  date  in  his  report.  The  pathogenic  agent  of 
Oriental  sore,  Oriental  boil,  Aleppo  boil,  Biskra  button, 
Delhi  sore,  ''Fly  bite,"  "Bess  el  temeur, "  etc.,  is  mor- 
phologically indistinguishable  from  the  Leishman-Dono- 
van  bodies  found  in  fatal  kala-azar  and  named  by  Eoss, 
"Leishmania  donovani;"  yet  there  are  certain  biologic 
differences  between  the  parasites  of  kala-azar  and  Ori- 
ental sore,  in  that  infections  by  the  so-called  Leishmania 
tropicum  are  limited  to  the  skin,  particularly  those  parts 
exposed  to  sunlight;  even  in  its  insect  host,  the  mosquito 
or  the  fiy,  it  has  the  necessary  light  by  translucence, 
whereas  the  Ijeishmania  donovani  of  kala-azar  requires 
darkness.  It  usually  attacks  children  before  the  seventh 
year  and  one  attack  generally  confers  inununity. 


'Darling,    S.    T. :      Dermal  Leishmaniasis   in   a   Native   Colombian,    Proc.    Canal   Zone 
Med.  Assn..  1911,  iv,  part  1,   154,  177. 


DISKASKS    Ol'    THE    SKIX  145 

The  sores  first  appear  as  ijai)ules  on  exposed  parts  of 
the  body,  but  other  parts  are  susceptible  to  autoinocula- 
tion.  There  is  a  nodular  form  which  may  be  single  or 
multiple  and  wliich  may  develop  no  further;  a  common 
t\-pe  is  the  solitary  ulcer.  The  incubation  period  is  from 
three  to  twenty  weeks  and  the  sore  ver}^  often  has  its 
origin  in  a  definite  fi}^  bite.  The  maximum  size  of  single 
ulcers  is  6  to  8  cm.  (2  to  3  inches)  which  is  attained  by 
progressive  ulceration  in  from  six  to  eighteen  months 
when  it  gradually  diminishes  and  the  ulcer  heals.  Tlie 
constitutional  symptoms  are  not  marked ;  pain  is  unusual 
and  it  is  not  a  very  serious  conditioii.  A  positive  diagno- 
sis is  made  by  finding  the  parasites  in  smears  or  sections 
of  tissue ;  the  bodies  are  also  easily  cultivated  from  very 
young  lesions  on  blood  agar  and  typical ' '  buttons ' '  can  be 
inoculated  on  either  man,  monkeys,  or  dogs.  On  monkeys 
and  dogs  tlie  nose  grows  the  "button"  most  successfully. 
The  treatment  will  continue  to  be  expectant  until  the 
exact  mode  of  infection  is  discovered;  early  excision 
gives  good  results.  The  repulsive  ulcerating  granulomas 
of  the  pudenda,  tropical  sloughing  phagedena,  gangre- 
nous proctitis,  etc.,  are  clinically  all  severe  mixed  pj^ogenic 
infections  usually  in  marantic  subjects.  The  etiology  of 
the  leg  ulcers  so  commonly  met  with  and  which  fre- 
quently become  cancerous  will,  when  more  care- 
fully studied  by  laboratory  methods,  undoubtedly  be 
cleared  up.  (See  page  128  under  Yaws  for  Castellani's 
treatment.) 

Tropical  Dermatomycosis 

This  is  a  large  sul\]ect  and  our  only  exact  knowledge 
of  it  is  due  mostly  to  the  researches  of  Castellani.®  A 
recapitulation  of  his  investigations  must  be  limited  to: 
Tinea  cruris.  Tinea  capitis  tropicalis,  Tinea  Flava  et 
nigra.  Intertrigo  saccharomycetica  and  Tinea  iml)ricata. 


sCastellani.  Aldo:     Tr.   Soc.  Trop.  Med.  and  Hyg.,   1913,  vi,  Nn.  3. 


i4(j  TROPICAL    SURGERY   AND    DISEASES 

' '  Tinea  cruris  has  been  known  to  tropical  practitioners 
under  the  name  of  'dhobie  itch.'  For  the  fungus  most 
commonly  found  in  such  cases,  characterized  by  the  pe- 
culiar 3"ellowish  color  of  its  colonies,  he  suggested  the 
term  'Trichophyton  cruris.'  In  1907  Sabouraud  investi- 
gated very  completely  the  same  condition  in  France 
which  he  called  '  Tinea  inguinalis. '  There  can  be  no  doubt 
that  this  is  the  dhobie  itch  of  tropical  authors,  or  Tinea 
cruris.  Tinea  cruris  may  be  caused  by  several  species  of 
fungus,  each  of  which  gives  rise  to  a  slightly  different 
variety  of  the  disease. 

"Up  to  the  present  Castellani  has  observed  the  follow- 
ing organisms:  Ep.  cruris,  Ep.  perneti,  Ep.  rubrum,  Tri- 
choph3^ton  nodoformans.  Epidermophj^ton  cruris,  Cas- 
tellani (1905);  S3aion5ans:  Ep.  inguinalis,  Sabouraud 
(1907);  Tr.  castellani,  Brooke  (1908)  causes  the  common- 
est and  best  known  type  of  the  disease  as  described  by 
all  tropical  authors,  and  in  Europe  by  Sabouraud.  The 
condition  is  characterized  by  large  festooned  patches  with 
elevated  margins  on  the  scrotoperineal  region  and  inner 
surface  of  the  thighs;  it  is  an  error  to  consider  Tinea 
cruris  as  always  localized  to  the  groin  and  armpits.  In 
many  cases  it  spreads  to  other  parts  of  the  body  (except- 
ing only  the  scalp) ;  it  may  start  on  the  chest  and  arms 
and  spread  to  the  groin  and  armpits,  or  it  may  even  not 
affect  these  regions  at  all.  Epidermophyton  rubrum, 
Castellani  (1909),  or  Ep.  purpureum.  Bang  (1911)  is 
characterized  b}^  the  beautiful  deep  red  pigmentation  in 
Sabouraud  and  glucose  agar.  It  induces  a  tjqDC  of  dhobie 
itch  which  has  a  great  tendency  to  spread  from  the  groins 
and  axillae  to  other  parts  of  the  body.  The  eruption  has 
often  an  eczematoid  appearance.  Trichophyton  nodo- 
formans, Castellani  (1911)  is  characterized  by  the  pecu- 
liar brick-red  color  of  the  cultures  on  Sabouraud 's  agar; 
this  color  is  lost  in  subcultures.     It  induces  a  peculiar 


DISEASES   OF   THE    SKIK  147 

type  of  dhobie  itch  with  deep  nodules  along  the  edge  of 
the  eruption.- 

''Tinea  capitis:  This  form  is  comparatively  rare.  All 
the  cases  were  due  to  the  same  endoectothrix  tricho- 
phyton; the  scalp  presented  in  all  cases  numerous  white 
patches  covered  by  an  enormous  number  of  pityriasis 
whitish  squamag.  The  patches  remain  bald  permanently. 
The  fungus  is  a  Trichophyton  endoectothrix,  practically 
identical  with  T.  violaceum  of  Sabouraud. 

"Intertrige  saccTiarmomycetica:  The  affection  is  ap- 
parently rare.  It  generally  attacks  the  scrotocrural  and 
axillary  regions.  The  affected  skin  is  red  and  there  may 
be  slight  exudation.  The  borders  of  the  eruption  are 
fairly  well  marked,  but  never  elevated.  In  most  cases 
there  is  little  itching  and  the  condition  may  recover 
spontaneously. 

''Tinea  flava:  This  dermatomycosis  is  confused  hj 
several  authors  with  the  pityriasis  versicolor  of  temperate 
zones,  but  the  researches  of  Jeanselme  and  Castellani  tend 
to  prove  that  it  is  a  separate  entity.  The  disease,  which 
is  extremely  common  in  many  countries,  is  characterized 
by  the  presence  of  bright  yellow  patches  found  on  various 
parts  of  the  body.  It  is  very  difficult  to  cure.  The  fungus 
is  a  Malassezia,  M.  tropica,  Castellani  (1905),  which  so 
far  has  not  been  grown. 

"Tinea  nigra:  This  was  first  described  in  1872  by  Man- 
son  in  China,  but  his  observations  were  forgotten,  as 
they  were  not  quoted  by  him  in  his  subsequent  publica- 
tions. It  was  redescribed  in  1905  by  Castellani  in  Ceylon. 
It  is  characterized  by  the  presence  of  black  patches  due 
to  a  fungus  Foxia  mansonia,  Castellani  (1905). 

"Tinea  imhricata:  The  etiology  of  this  disease  has 
been  the  subject  of  numerous  controversies.  In  recent 
years  the  general  opinion  has  been  that  aspergillus-like 
fungi  are  its  real  causes.    From  his  investigations  Castel- 


148  TROPICAL  suRCJERY  a:n'd  diseases 

lani  considers  that  aspergilli  and  aspergillus-like  fungi 
have  nothing  to  do  with  the  condition  and  that  when  they 
are  present  they  are  merely  saprophytes-  or  contamina- 
tions; that  they  are  not  trichophytons;  they  resemble 
more  the  achorions.  He  produced  the  disease  typically 
in  man  by  inoculating  j)nre  cultures  of  two  species  of 
fungi  which  he  isolated,  the  Endodermophyton  concen- 
tricimi  and  End.  inclicum. 

" Tricliomijcosis  flava,  rubra  et  nigra  of  the  axiUarij 
regions:  The  affected  hairs  present  nodular  formations, 
plainly  visible  to  the  naked  ej'-e,  of  rather  soft  consist- 
ency, and  easily  removable  by  scraping.  The  formations 
are  either  ^^ellow  or  black,  or  less  frequently  red;  the}^ 
may  be  ver}^  abundant  and  form  a  yellow  or  black  or  red 
sheath  round  the  hair.  By  the  use  of  the  microscope 
these  nodules  are  seen  to  consist,  in  the  yellow  variety, 
of  enormous  numbers  of  bacillar^^-like  bodies,  embedded 
in  an  amorphous  cementing  substance;  in  the  red  and 
black  varieties  large  groups  of  cocci  are  observed  as 
well.  The  yellow  variety  is  due  to  a  Nocardia  (N.  tenuis), 
the  mycelial  segments  of  which,  being  very  thin,  have  a 
bacillary  appearance.  The  black  variety  is  due  to  a 
symbiosis  between  the  same  Nocardia,  and  a  black  pig- 
ment-producing coccus,  which  Castellani  described  under 
the  name  of  Micrococcus  nigrescens.  The  red  variety  is 
caused  by  a  symbiosis  between  the  same  Nocardia  and  a 
red  ijigment-iDroducing  coccus.  Diagnosis:  The  condi- 
tion must  be  differentiated  from  the  various  forms  of 
Trichosporosis  (piedra,  etc.),  and  from  Leptothrix  of 
temperate  climates.  It  is  easih^  distinguished  from  the 
former  by  the  fact  that  Nocardia  tenuis  in  contrast  to  the 
various  species  of  Trichosporon  is  an  extremely  thin  fun- 
gus; it  differs  from  the  latter  by  the  nodules  being  soft, 
easily  removed,  and  by  the  hairs  not  becoming  brittle; 
moreover,  it  is  easily  curable.  Treatment:  A  good  method 
of  treatment  is  dabbing  the  hair  two  or  three  times  daily 


MVIUCTOMA,    on        JMADURA     I'OOT 


!4!) 


Avitli  a  solution  of  formalin  in  spirit  (oi  to  ovi)  and  apply- 
ing a  snlpliur  ointment  (2  to  5  per  cent)  at  nig'ht." 

In  1906,  in  a  case  of  amebic  dysenter}^  and  suspected 
hepatic  abscess,  I  found  motile  aniebas  in  a  general  pus- 
tular cutaneous  eruption;  in  this  same  case  Musgrave 
and  Clegg  found  amebas  in  the  circulating  blood,  Keng^ 
(1914)  describes  a  dermatitis  of  small,  hard,  red,  discrete 
papules,  like  beginning  smallpox,  which  became  vesicles, 
ruptured  and  scabbed  over;  in  other  cases  it  was  a  dif- 
fuse spreading  erythema  with  pus  in  the  subcutaneous 
tissues;  each  form  seemed  to  spread  from  the  region  of 
the  anus  of  amebic  dysentery  cases  and  Entameba  his- 
tohiica  was  found  in  each  lesion. 


Fig.  58. — Madura  foot.     (From  a  specimen  in  the  Army  Medical  Museum,  Washington.) 


MYCETOMA,  OR  * 'MADURA  FOOT" 

Mycetoma,  or  Madura  foot,  is  a  fungus  condition  of  th<^ 
foot,  rarely  of  the  hand  or  other  parts  of  the  body,  and 

'•'Kcng:     Jour.    Trop.   :\Ied.,    1914,   xvii,   p.    193. 


150  TROPICAL    SURGERY    AND    DISEASES 

never  of  the  internal  organs.  It  is  found  in  all  warm 
countries ;  is  common  in  India ;  runs  a  verj  chronic  course 
and,  unless  amputated,  terminates  in  death  after  many 
years  of  exhaustion  (Fig.  58).  The  foot  becomes  en- 
larged to  two  or  three  times  the  normal ;  all  of  its  tissues 
fuse  by  an  oily  degeneration  into  a  cystic  mass  full  of 
sinuses  containing  the  mj^cotic  collections  which  ooze 
from  openings  on  the  surface.  It  begins  usually  on  the 
sole  by  slow  formation  as  small  painless  swellings,  per- 
haps half  an  inch  in  diameter,  which  rupture  in  about  a 
month  discharging  a  viscid,  syrupy,  synovial,  and  at 
times  bloody  fluid  containing  minute  rounded  particles  of 
various  colors,  white  or  yellow,  black  or  pink,  from 
which  the  three  clinical  varieties  derived  their  names ;  in 
these  granules  are  found  the  pathogenic  fungi;  pyogenic 
invasion  is  usually  a  complication.  Besides  the  strepto- 
thrix  m.ycetomi  Laveran  and  the  streptothrix  madurse, 
Brumpt  described  six  different  fungi  which  can  cause 
clinical  mycetoma;  four  of  them,  provisionally,  are  among 
the  mucedineae. 

AINHUM  AND  CHIGGERS 

The  surgical  curiosity  called  ainlium,  a  disease  of  flat- 
footed,  barefooted  peoples,  commonest  in  Africa,  which 
results  in  a  cicatricial  band  amputation  of  toes,  usually 
the  little  toe,  according  to  Creighton  Wellman"  (1914), 
is  probably  caused  b}^  chiggers.  In  West  Africa  he  no- 
ticed, "that  the  chigger  has,  even  in  healthy  feet,  a  pre- 
dilection for  the  under  surface  of  the  little  toe,  and  espe- 
cially so  if,  as  is  often  the  case  Avith  barefooted  peoples, 
the  skin  is  cut  or  torn.  It  is  well  known  to  those  who 
have  studied  the  insect  that  it  invades  abraded  or  irri- 
tated surfaces  oftener  than  sound  skin.  The  fold  under 
the  proximal  joint  of  the  little  toe  corresponding  to  the 


^"Wellman.   Creighton:      Forchheimer-nillings,   Tlierapeusis   of  Internal   Diseases,   D. 
Appleton  &  Co.,  iv,  690. 


AINHUM   AND    CHIGGERS 


151 


web  between  the  toes  is  the  point  where  wounds  are 
oftenest  made  by  the  sharp  grasses,  througli  wliich  the 
native  walks  and  runs.  A  principal  reason  for  this  is 
that  the  little  toe  of  barefooted  blacks,  especially,  lies 
separate  from  the  otliers  at  an  angle  due  to  anatomic 
reasons  connected  with  flat-footedness.  When  wounds 
are  made  here  the  chiggers  persistently  invade  them  and 


Fifif.    59. — Ainhum.      (From    Manson.) 

must  be  removed  constantly.  So  these  insects  seem  to 
play  a  part,  in  many  instances  at  least,  in  the  continued 
irritation  which,  especially  in  blacks  who  have  fibrogen- 
etic  tendency,  leads  to  the  contracting  fibroses  resulting 
in  ainhum."     (Fig.  59.) 


THE   CHIGGER,   SARCOPSYLLA  PENETRANS, 
EWUNDU,  OR  SAND  FLEA 

The  chigger  plays  a  heavier  role  in  the  production  of 
mutilation  and  disease  than  hitherto  suspected.  It  is  a 
common  pest  originally  from  South  America  which  has 


152 


TROPICAL    SURGERY    AXD    DISEASES 


traversed  Africa,  reached  India,  and  seems  to  be  on  its 
Avay  around  the  world.  Welhnan  says,  "it  usually  pro- 
duces no  serious  lesions,  yet  I  have  seen  shocking-  deformi- 
ties, loss  of  limbs,  gangrene,  septicemia,  and  death  re- 
sult, directly  or  indirectly,  from  its  presence.     Apropos 


i 

^^ik 

A 

\ 

"  "^^^ss* 

^/7 

Fig.       60. — Female      pregnant      chigger  Fig.      61. — Male     cliigger     (Sarcopsylla 

(Sarcopsylla  penetrans).  Magnified.  (Af-  penetrans).  Magnified.  (After  Well- 
ter  Wellman.)  man.) 

of  its  being  the  possible  transmitter  of  specific  micro- 
organisms, I  may  mention  that  I  have  found  various  bac- 
teria, including  Bacillus  lepr^  in  chiggers  but  the  insect 
has  not  been  carefully  studied  to  determine  if  it  be  a  true 
carrier  of  such  germs.''     (Figs.  60  and  61.) 


GOUNDOU,  OR  ANAKHRE 

This  curious  disease  was  first  described  in  1882  as 
"the  horned  men  of  Africa."  It  consists  of  synmietric 
bony  growths  of  the  nasal  bones  and  of  the  nasal  processes 
of  the  superior  maxillary  bones.  It  usually  begins  in 
childhood,  and  also  affects  monkeys.  The  growths  ordi- 
narily attain  half  a  hen's  egg  in  size  and  impart  a  simian 
expression  to  the  face.  (Fig.  62.)  The  overlying  skin  is 
not  involved;  the  nostrils  are  bulged  inward  and  are 
partially  obstructed,  but  no  lesions  of  the  mucosa  have 
been  observed  in  the  mature  cases.  Its  beginnings  are 
characterized  l)y  severe  headaches  and  a  sanguinopuru- 


GorxDOT',  on  axaktiiie 


153 


lent  discharge  from  tlie  nose  for  six  or  eight  months 
when,  according  to  ]\lanson,  the  pain  and  discharge  sub- 
side but  the  swellings  increase  painlessly  and  gradually 
and  in  extreme  cases  may,  by  their  immense  size,  destroy 
the  eyes  l)y  pressure.  Xo  careful  histopathologic  studies 
seem  to  have  been  made  of  the  tumors,  but  the  final  result 
seems  to  be  purely  a  bony  growth.  Maclaud  (1895)  is 
of  the  oijiiiioii  that  the  disease  originates  from  the  larvae 


Fig.    62. — Goundou   and   leontiasis    (Honduras).      (U.    S.    Xavy    IMedical    Bulletin.; 

of  some  insect  in  tlie  nostril  and  tliere  is  nnich  to  sustain 
this  the(»r\-.  It  has  long  ht'vn  known  that  several  species 
of  flies  deposit  their  eggs  in  the  nasal  cavities  where  the 
larvaj  develop  rapidly  and  if  the  secondary  microbic  in- 
fections are  severe  enough,  death  has  often  resulted.  The 
early  s3anj)toms  of  goundou  are  plainly  due  to  an  active 
inflammatory  process  in  the  anterior  nares  and  when 
the  specific  pathogenic  agent  is  discovered,  it  will  prob- 
ably be  found  to  be  a  myiasis.  The  growths  nrc  easily 
removed  by  chiseling,  and  there  is  no  tendency  to  recur. 


154  TROPICAL  SURGERY  AND  DISEASES 

Botreau-Eoiissel  {Bull.  Soc.  Path.  Exot.  June,  1917, 
vol.  X,  pp.  480-483)  saw  117  cases  of  gouiidon  on  the 
Ivory  Coast  and  removed  the  paranasal  tumors  sub- 
periosteally  108  times,  107  times  with  success ;  he  groups 
them:  1.  Paranasal  tumors  the  only  symptom,  48.  2. 
Paranasal  tumors  the  most  striking  symptom,  hut 
other  hyperostoses  present,  62.  3.  No  paranasal  tumor 
present  or,  if  present,  secondary  to  other  hyperostoses, 
7.  The  bones  most  frequently  affected  were  the  tibia, 
58 ;  upper  jaw,  14 ;  lower  jaw,  13 ;  forearm  and  fibula,  4 
each ;  humerus,  femur  and  clavicle,  2  each ;  malar  bone,  1. 
There  Avas  never  any  history  of  intranasal  infection  or 
discharge  but  always  one  of  an  eruptive  disease  called 
''dobe"  lasting  from  three  to  twelve  months.  The  dobe 
was  yaAvs  and  in  the  serum  of  the  frambesial  nodules 
Spirocheta  castellani  was  demonstrated. 

BUBOES 

Buboes  of  the  inguinal  region  in  men,  accompanied  by 
a  mild  degree  of  fever  and  considerable  pain,  running  an 
indolent  course,  with  slight  tendency  to  su]3puration,  and 
nonvenereal  so  far  as  any  evidence  is  concerned,  are 
quite  common  in  hot  countries.  The  disease  was  often 
encountered  in  the  Philippines,  especially  among  white 
men  during  the  military  occupation.  Many  glands  were 
involved  and  the  tendency  was  to  become  chronic.  Un- 
der expectant  and  local  treatment  a  low  grade  inflamma- 
tion, with  softening,  occurred  in  the  majority  of  cases 
in  two  or  three  weeks.  Although  no  venereal  disease  was 
discoverable,  habitual  and  even  excessive  venery  was 
admitted  by  many  of  the  patients.  No  evidence  of  rec- 
tal or  pelvic  disease  was  evident,  and  sections  of  the 
glands  showed  inflammatory  changes  only.  The  suspi- 
cion that  the  condition  in  Manila  was  due  to  surface  ab- 
sorption of  gonococci  or  other  organisms  during  venereal 
excesses  could  not  be  substantiated  bacteriologically;  the 


TYOGEiS'lC    lA^l-'ECTiONS  155 

only  organism  discoverable  by  the  incomplete  methods 
employed  was  the  streptococcus  in  the  nodes  that  suj)- 
purated.  Little  benefit  was  apparent  from  local  therapy 
and  rest  in  bed;  compk^te  removal  of  the  nodes,  which 
often  shelled  out  easily,  was  found  to  be  the  most  satis- 
factory treatment. 

Some  authors  consider  the  condition  due  to  a  weak 
strain  of  plague  bacilli,  apestis  minor,  or  to  a  malarial 
cause,  etc.  Castellani  and  Chalmers  describe  a  subacute 
and  chronic  form  of  bubo,  and  Barlow,"  in  Honduras, 
encountered  an  epidemic,  nonsuppurating  form  which 
was  limited  to  one  gland;  numerous  punctures  yielded 
only  sterile  juices;  it  had  a  sharp  onset  with  pain,  fever 
(102°  F.)  and  redness  which  subsided  in  a  Aveek  or  two. 
Salicylates,  40  grains  or  more  daih^.  Barlow  claims  are 
a  specific  and  that  if  begun  on  the  first  or  second  day  the 
patient  may  return  to  work  in  three  days. 

TETANUS 

This  infection  deserves  special  mention  only  because 
it  is  too  often  a  postoperative  complication;  it  was  in 
Manila,  at  least  in  the  early  days;  and  tropical  surgical 
clinics  should  always  be  on  their  guard  against  it  and 
prepared  to  combat  it  promptly. 

PYOGENIC  INFECTIONS 

Pyogenic  complications  of  Far  Eastern  surgery  have 
little  to  distinguish  them  from  those  of  other  lands.  In 
the  warm  and  moist  parts  of  the  earth  microorganisms 
of  both  the  animal  and  the  vegetable  kingdom  naturally 
flourish  perennially  and  in  profusion  as  do  all  tropical 
growths.  Much  has  been  written  of  the  necessitj^  of 
doubling  and  trebling  the  antiseptic  surgical  iDrecautions 
in  the  Tropics  on  this  account,  but  the  onh^  permissible 

"Barlow,  N.:     Epidemic  Climatic  Bubo,  Am.  Jour.  Trop.   Dis.,   1914,  i,  No.    11,   787. 


156 


TROPICAL    SUEGERY    AXD    DISEASES 


teclinic  for  sterilizing  everything  that  comes  in  contact 
with  a  Avonnd,  Avherever  an  operation  is  to  be  performed, 
is  the  one  that  can  not  be  improved  upon;  namely,  the 
one  that  is  standard  and  that  is  in  use  wherever  the  best 
surgery  is  done;  climate,  amount  and  ubiquity  of  germ 
life  have  nothing  to  do  with  it.  If  there  is  any  peculiarity 
about  microbic  wound  infection  in  the  Tropics,  it  is  jDrob- 
ably  in  that  the  streptococcus  is  so  rarely  encountered 


Fig.  63. — Dr.  W.'s  hand.  The  photograph  was  taken  at  a  time  when  retro- 
gressive changes  had  set  in.  At  the  tip  of  the  forefinger  some  remains  of  the  cauli- 
flower-like granulations  may  still  be  seen. 

ill  wounds  compared  to  its  prevalence  in  temperate  zones. 
The  results  of  pyogenic  infections  among  natives  are  very 
frequent  and  often  serious,  but  this  is  due  to  their  un- 
hygienic lives  and  ignorance  of  asepsis  or  antisepsis. 

Two  cases  of  a  peculiar  form  of  hand  infection,  one  in 
a  hospital  surgeon  and  one  in  a  nurse,  due  to  an  organism 
resembling  the  Koch- Weeks  bacillus  were  reported  by 


rvo(ii':N ic"   IX I'ECTroxs 


157 


McDill  and  Wherry.' '  The  surgeon  had  been  treating- 
cases  of  acute  suppurating  conjunctivitis  and  a  small 
painful  papule  appeared  on  the  tip  of  the  right  index 
finger;  four  days  later  it  was  incised  but  no  pus  was 
found;  two  days  after  this  the  nurse  lanced  it  and  pricked 
the  pulp  of  the  index  finger  of  her  left  hand  during  the 
operation;  the  wound  secretion  Avas  scant  and  clear  and 
tlie  wound  became  a  eauliilower-like  mass  (Fig-  63) ;  by 


Fig.    64. — A    photograjih    of    ^Nliss    B.'s    hand,    taken    al    a    time    when    gangrene    of    the 
forefinger    had    set    in. 


the  end  of  the  second  week  the  pain  was  intense  and  the 
wound  was  thoroughly  curetted;  by  the  end  of  the  third 
week  it  was  worse  and  greatly  swollen  and  a  little  pus 
was  found  on  the  twenty-eighth  day;  temperature  Avas 
never  over  102'  F.;  the  ])ain  was  intense,  there  was  great 

^^McDill  and  Wherry:     A  Report  on  Two  Cases  of  a  Peculiar  Form  of  Hand  Infec- 
tion, Jour.  Infect.  Dis.,   1904,  i,   No.   1,  58-71. 


158  TROPICAL  SURGERY  AND  DISEASES 

mental  depression  and  complete  loss  of  appetite;  treat- 
ment had  no  apparent  effect.  In  another  month 
complete  resolution  occurred  with  good  function.  The 
nurse  sterilized  her  wound  at  once  with  bichloride 
solution  and  applied  95  per  cent  alcohol  com- 
presses, but  in  three  days  a  painful  vesicle  formed; 
continuous  packs  of  a  very  cold  saturated  solution 
of  acetate  of  aluminum  were  employed ;  no  discharge  ap- 
peared in  the  incision;  incessant  stabbing  pains  per- 
sisted; the  digital  arteries  pulsated  ^^ith  a  wirelike 
tension;  only  twice  the  temperature  reached  102°  F.;  pro- 
nounced mental  and  plwsical  prostration,  vigilance,  sleep- 
lessness and  vomiting  uninfluenced  but  little,  even  by 
morphine,  characterized  the  condition  for  three  weeks. 
Twice  the  soft  tissues  of  the  wound  were  curetted  to  the 
exposed  bone  with  relief  for  only  thirty-six  hours ;  the 
whole  hand  was  swollen  at  the  end  of  twenty  days  when 
the  infected  area  was  again  cleaned  out  and  the  tendon 
sheaths  drained  toward  the  palm.  Gangrene  of  the  end 
of  the  finger  became  apparent  (Fig.  6-±)  and  five  weeks 
after  the  onset  the  finger  was  amputated  when  three 
inches  of  necrotic  long  flexor  tendon  pulled  away  easily. 
Dr.  Wherry's  bacteriologic  examinations  and  inocula- 
tion experiments  on  rabbits,  guinea  pigs  and  monkeys 
led  him  to  consider  the  organism  as  identical  with  or 
as  a  closely  related  type  of  the  Koch-Weeks  bacillus. 

THE  ARTHRITIDES 

Both  rapid  and  chronic  invasion  of  the  joints  from 
localized  infection  foci  anywhere,  from  gonorrhea,  and 
from  syphilis,  with  local  and  general  symptoms,  are  not 
infrequent  in  the  Tropics,  and  they  further  closely  re- 
semble these  conditions  elsewhere  by  being  called  "rheu- 
matism. ' '  The  generally  reduced  bodily  resistance  of  the 
poorer  classes  is  a  tangible  factor  and  the  injurj^  to  which 


THE    AETHIUTIDES  159 

the  disease  is  usually  traced  as  the  proximate  cause  is 
almost  always  a  slight  trauma  or  a  chilling  of  the  part  by 
exposure.  Probably  three-fourths  of  the  cases  are  due 
to  the  organisms  of  lues  and  gonorrhea,  especially  in  the 
seaboard  centers  of  population.  These  cases  of  venereal 
origin,  when  correcth^  diagnosed,  usually  yield  readily  to 
vigorous  specific  treatment  combined  with  attention  to 
the  general  metabolic  disease. 


PART  II 

OBSERVATIONS  ON  CHINA,  JAPAN,  AND  THE  PHIL- 
IPPINES, AND  COLLATED  ANSWERS  TO  A  QUESTION- 
NAIRE OF  FIFTY-THREE  INQUIRIES  SENT  TO  COUN- 
TRIES IN  AND  ABOUT  THE  TROPIC  ZONE  IN  1911* 


CHAPTER  X 

OBSERYATIOXS    OX    CHINA,    JAPAN,    AND    THE 
PHILIPPINES 

CHINA 

China  with  her  four-thousand-year-old  ideals  and  tra- 
ditions and  the  tremendous  inertia  of  her  four  hundred 
million  people,  devoid  of  public  sentiment,  real  patriotism 
and  a  national  consciousness,  presents  to  the  medical  man 
and  sanitarian  an  almost  unapproachable  problem.  The 
enthusiastic  Occidental  who  longs  to  help  China  clean 
house  and  who  is  baffled  at  times  by  her  indifference  to, 
or  utter  rejection  of,  his  well-meant  and  really  beneficent 
plans  for  her  welfare,  must  not  forget  how  deep  and  long- 
she  has  drunk  of  the  drug  of  self-sulficiency  and  com- 
placency. For  the  past  twenty  years  we  have  heard  much 
of  "awakened  China"  and  yet  today  among  those  who 
have  worked  hard  for  her  regeneration  there  is  cause  for 
profound  discouragement  if  it  is  not  realized  that  she  is 


*  Author's  Note:  I  am  assured  by  surgeons  recently  from  China  that  the  answers 
to  this  questionnaire  do  not  in  some  respects  represent  knowledge  concerning  medical 
conditions  today;  that  there  has  been  a  very  decided  improvement  since  the  ^lanchus 
were  banished  and  that  a  survey  now  would  reveal  statistics  of  real  value  and  that 
there  has  been  a  very  great  advance  made  in  surgerv  since  1910  and  especially  since 
1912. 

161 


162  TROPICAL    SURGERY    AXD    DISEASES 

yet  dazed  and  stupefied  from  the  effects  of  her  age-long- 
narcotic  dreams.  It  has  taken  all  of  the  successive  blows 
dealt  at  her  ''universal  sovereignty"  fetish,  her  defeat 
by  Japan  in  1894,  by  the  allied  powers  in  1900,  the  treat- 
ment of  her  as  a  negligible  quantity  in  the  Eusso-Japa- 
nese  war  fought  on  her  soil  in  1904-,  the  encroachments 
of  all  the  European  nations,  and  lastly,  the  startling- 
demands  of  Japan  to  bring  home  to  at  least  her  ruling- 
powers  that  the  reason  for  her  humiliation  is,  as  a  for- 
mer President  once  admitted,  her  weakness. 

It  would  seem  that  now  is  a  fitting-  time  to  call  to  the 
attention  of  those  who  are  responsible  for  China's  future 
that  this  weakness  has  its  origin  largel}^  in  the  lack  of 
appreciation  of  the  value  to  the  state  of  healthy  able- 
bodied  citizens,  and  of  the  fact  that  it  is  impossible  to 
kindle  the  fires  of  patriotism  and  to  create  an  adequate 
force  for  national  development  and  protection  in  sick 
bodies.  Convince  the  Chinese  that  the  efficiency  and 
energy  of  their  country  is  reduced  over  seventy  per  cent 
by  the  chronic  curable  diseases  of  tuberculosis,  malaria, 
syphilis,  and  intestinal  parasites,  including  five  million 
cases  of  eye  diseases,  and  that  these  conditions  can  be 
remedied,  and  they  will  at  least  tolerate  the  modern  medi- 
cal man  and  sanitarian  as  tliey  already  do  the  foreign  po- 
litical adviser,  engineer,  and  railway  builder,  jDarticularly 
under  the  condition  that  native  controlled  institutions 
and  a  body  of  Chinese  medical  men  will  be  developed. 
The  sine  qua  non  in  China  is  government  cooperation;  no 
headway  can  be  made  in  the  treatment  of  a  whole  people 
totally  ignorant  of  medical  matters  without  the  initiative 
of  their  rulers  in  the  establishment  of  medical  institutions 
and  the  enforcement  of  the  immediately  urgent  therapy  by 
official  power. 

So  far,  efforts  to  remedy  the  physical  ills  of  the  Chinese 
people  have  been  made  only  in  connection  with  the  teach- 
ing-^ of  religion  and  have  scarcely  ruffled  a  small  part  of 


OBSERVATIONS    OX    CIITXA  163 

tlie  surface  of  the  problem.  For  over  one  hundred  years 
the  medical  missionaries  of  all  countries  have  done  their 
best.  There  are  at  present  ninety-three  Protestant  mis- 
sionary societies  at  work  in  various  parts  of  China,  There 
are  about  four  thousand  Protestant  missionaries,  includ- 
ing wives  and  unmarried  women  Avho  constitute  half  their 
number,  and  of  these  nearly  five  hundred  are  medical 
men  and  women.  There  are  close  to  twelve  hundred 
foreign  and  six  hundred  Chinese  Catholic  T)riests  also  in 
the  field.  Hundreds  of  the  missionaries  and  their  con- 
verts have  suffered  martyrdom  and  time  and  again  they 
have  been  driven  out  and  all  of  their  property  destroA^ed. 
Their  greatest  service  has  been  in  the  favorable  impres- 
sion they  have  made  on  the  Chinese  and  the  proofs  they 
have  given  of  the  genuine  disinterestedness  of  their  mo- 
tives. With  the  Oriental,  with  whom  self-interest  is 
paramount  and  who  has  heretofore  not  been  able  to  con- 
ceive of  others  being  without  it,  this  has  not  been  easy 
of  achievement  and  in  sjDite  of  all  the  depreciating  stories 
circulated  about  the  missionaries,  their  work  has  been  of 
incalculable  value  and  has  become  the  basis  of  much 
mutual  understanding  in  place  of  suspicion  and  distrust. 
The  struggles  against  incredible  odds  and  with  meager 
support  of  the  mission  medical  men  and  women  to  better 
conditions  is  a  great  story  of  devotion  and  unselfishness. 
It  is  through  their  work  principally  that  the  evangelistic 
members  have  been  able  to  reach  the  Chinese.  They  have 
founded  about  one  hundred  hospitals  and  eleven  medical 
schools,  skeletal  organizations  mostly,  but  to  which  can 
be  added  the  vital  elements  necessary  to  develop  them 
to  great  usefulness.  So  far  the  schools  have  turned  out 
less  than  two  hundred  poorly  trained  Chinese  physicians, 
while  tens  of  thousands  of  first-class  men  are  needed, 
and  the  hospitals,  through  lack  of  staff  and  equipment, 
are  not  fulfilling  the  real  functions  of  hospitals  to  the 
communities  in  which  they  exist.    The  number  of  foreign 


164  TROPICAL    SURGERY   AND    DISEASES 

trained  native  doctors  is  small;  they  have  taken  lucrative 
positions  and  their  influence  on  the  general  health  situa- 
tion is  very  slight.  The  medical  members  of  the  various 
missions  have  wisely  formed  a  union  for  the  purpose  of 
organized  effort  in  colleges,  societies  and  publications, 
and  are  doing  splendid  work.  There  are  men  in  this 
association  who  only  need  backing  to  go  to  the  top  of 
their  profession. 

It  is  to  be  hoped  that  the  ruling  powers  of  China  will 
take  up  the  problems  of  health  and  sanitation  without 
delay,  and  that  they  will  do  so  ^^ith  a  long  look  ahead, 
will  commit  themselves  to  a  fixed  program  covering  at 
least  two  decades,  and  be  guided  by  those  foreign  advis- 
ers whose  disinterestedness,  wisdom  and  abilit}^  are  un- 
questioned. With  the  exjperience  of  all  nations  and  the 
willing  cooperation  of  the  best  men  of  friendly  powers  at 
her  disposal,  China  has  an  opportunity,  unique  in  the 
world's  history,  to  acquire  the  strongest  educational  sys- 
tem of  any,  because  her  field  has  not  3"et  been  invaded  to 
any  appreciable  extent  by  the  unfit  and  the  untrained. 

Medical  science,  long  centralized  in  Europe,  is  shifting- 
westward  to  America  in  many  respects.  Japan,  still  fur- 
ther west,  is  already  attracting  attention  to  her  ability 
to  take  and  hold  a  leading  place,  and  in  another  century 
or  less  it  is  not  unreasonable  to  expect  that  if  China  will 
drink  deep  from  the  fount  of  pure  science  onl}^,  she  can 
become  the  actual  ''middle  kingdom"  of  the  world  of 
medicine  and  science.  If  China 's  little,  nation-disturbing 
neighbor,  Japan,  can  accomplish  such  wonders  in  med- 
icine and  military  surgery  in  thirty  years  that  the  rest  of 
the  world  must  govern  itself  accordingly,  China's  colos- 
sal ]oride  should  at  least  impel  her  to  make  a  sustained 
effort  to  demonstrate  her  ability  to  not  only  do  likewise 
but  to  do  so  on  a  far  grander  scale. 

Even  though  the  psychologic  period  is  apparently 
present  and  even  though  the  proposition  is  to  us  so  plainly 


OBSERVATIONS    ON    CHINA  165 

beneficent  and  it  is  so  obvious  that  great  and  certain 
power  follows  real  knowledge,  in  order  to  receive  con- 
sideration, the  idea  must  be  presented  to  the  Chinese  with 
due  regard  to  their  peculiar  state  of  mind  and  habits  of 
thought  or  tliere  is  always  danger  of  it  being  received 
with  impenetrable  apathy.  It  must  be  remembered  that 
the  obvious  and  essential  to  the  Occidental  mind  may  be 
an  uninteresting  triviality  to  the  Oriental,  that  much  of 
our  enthusiasm  and  zeal  is  inexplicable  to  him  and  that 
there  is  a  great  necessity  to  proceed  slowly  and  with 
calmness  in  presenting  any  problem.  ''A  Chinaman  will 
not  hear  patiently  in  a  month  what  a  Frenchman  can 
say  in  an  hour. ' '  But  there  is  one  opening  in  his  armor 
of  phlegmatic  calm  through  which  he  may  be  reached. 
He  is  intensely  appreciative  of  success.  Once  he  is  shown 
that  a  thing  really  works  and  accomplishes  its  object,  his 
sympathy  and  admiration  are  enlisted  because  success  to 
him  means,  not  only  so  much  in  dollars  and  cents,  but  to 
his  superstitious  mind  it  spells  the  favor  of  his  gods  as 
well. 

Although  every  disease  is  prevalent  in  China,  the  epi- 
demic diseases  devastating  at  times  and  leprosy  not  seg- 
regated and  although  the  Chinese  generally  use  cooked 
food  and  drink,  the  answers  to  my  questionnaire  of  1911 
from  all  parts  of  China  showed  that  the  predominating 
diseases  were  tuberculosis,  syphilis,  and  intestinal  para- 
sites. When  statistics  are  available,  malaria  will  prob- 
ably also  be  found  in  this  group.  Surgery,  except  for  the 
most  obvious  and  pressing  conditions  which  can  be 
handled  by  ordinary  skill  and  equipment,  is  as  yet  un- 
developed in  China  except  in  university  centers. 

Medicine  as  Practiced  by  the  Chinese* 

Since  the  opening  of  the  Canton  Hospital  in  1838,  the  advance  of 
Western  medicine  in  China  has  been  .gradual  but  continuous.     Of  recent 

*By  William  W.  Cadbury,  M.D.,  Physician  to  the  Canton  Christian  College,  Canton, 
China.  Reprinted  from  Med.  Rec.,  New  York,  Aug.  26,  1916.  Published  by  permission 
of  Dr.  Cadbury. 


166  TROPICAL  SURGERY  AXD  DISEASES 

years  the  medical  profession  of  the  United  States  has  shown  consider- 
able interest  in  the  hospitals  and  medical  schools  established  by  mission- 
aries, and  this  interest  has  been  greatly  intensified  by  the  recent  an- 
nouncements of  the  China  Medical  Board  of  the  Rockefeller  Foundation 
that  it  is  their  intention  to  assist  and  carry  on  the  institutions  already 
established  at  Peking  and  Shanghai.  It  is  the  purpose  of  the  Board  to 
make  the  schools  equal  to  or  even  better  than  any  now  existing  in  the 
United  States. 

In  view  of  this  greater  interest  of  the  medical  profession  of  our  coun- 
try, there  is  doubtless  more  or  le^s  speculation  as  to  what  is  the  status 
of  Chinese  medicine  as  it  has  existed  and  still  exists  among  the  people 
of  this  vast  empire.  The  notes  here  submitted  are  partly  the  result  of 
personal  observation  in  the  city  of  Canton,  and  partly  of  conversations 
with  a  Chinese  doctor  of  the  old  style.  I  have  also  referred  largely  to 
the   articles  noted  below  under  references. 

Medicine  in  China  may  be  considered  under  two  divisions — the  purely 
superstitious,  which  depends  on  charms  and  magie  and  is  largely  fos- 
tered by  the  Taoist  priests,  and  the  art  of  medicine  as  practiced  by 
the  Chinese  doctor.  These  two  phases  of  treatment  of  the  sick  are 
closely  interwoven  with  one  another  so  that  it  is  sometimes  impossible 
to  draw  the  line  between  them. 

Let  us  first  consider  the  sux^erstitious  practices  and  beliefs.  In  the 
city  of  Canton  may  be  found  temples  dedicated  to  the  "Spirit  of  Med- 
icine," or  healing.  .The  ignorant  people,  especially  women,  believe  that 
the  deity  presiding  in  these  temples  can  restore  health  upon  the  pay- 
ment of  small  sums  of  money  to  the  priest  and  the  performance  of  cer- 
tain rites. 

Chinese  medicine,  like  philosophy,  rests  on  a  dualistic  basis.  At  the 
bottom  of  all  the  laws  of  the  universe  are  two  principles,  the  "yang" 
and  the  "yin. "  They  are  generally  represented  by  a  circle  divided 
into  two  x^ai'ts,  each  of  which  is  a  comma-shaped  object  resembling  a 
serpent.  One  is  white  and  the  other  black,  or  one  is  green  and  the 
other  red.  The  circle  represents  the  great  absolute  and  the  two  divisions 
within  it  the  "yaug"  and  the  "yin."  Again  the  "yang"  or  male 
element  or  force  is  represented  by  straight  lines,  and  the  "yin"  or 
female  element  by  broken  lines.  Thus  the  pantagram  was  devised  by 
a  Chinese  emperor  about  the  year  2900  B.  C.  This  is  made  up  of  com- 
binations of  straight  and  broken  lines  surrounding  the  circle  and  its  two 
divisions,  making  a  perfect  emblem  of  the  balancing  of  the  forces  of  the 
universe.  Over  many  a  doorway  in  China  this  sign  is  disj)layed  to  warn 
off  evil  spirits.  The  principle  of  duality  typified  by  the  "yang"  and 
"yin"  is  more  comi^rehensive  than  "male"  and  "female."  They 
stand  for  positive  and  negative,  the  sun  and  the  moon,  light  and  dark, 
acid  and  base,  heaven  and  earth,  and  they  correspond  to  Ohrmuzd  and 
Ahriman  of  the  Zoroastrians,  Osiris  and  Isis  of  the  Egyptians,  the  even 
and  the  odd  of  Pythagoras. 

The  universe  with  its  dual  forces  is  a  macrocosm.     Man  is  the  micro- 


OUSEltVATIOXS    ON    THIXA  !()< 

fosiii.  Thus  ^\■c  read  that  as  heaven  has  its  orders  of  stars,  and  earth 
its  currents  of  water,  so  man  has  his  pulse.  As  earth  has  its  water 
courses,  called  lakes,  springs,  etc.,  so  man  lias  his  courses  in  the  pulse — 
the  three  "yang"  and  the  three  "yin." 

The  priests  explain  these  forces  of  the  universe  by  personifications  in 
the  form  of  evil  spirits,  or  devils,  and  the  people  are  kept  in  constant 
fear  of  these  demons  of  tlie  air  whicli  they  believe  arc  constantly  bent 
on  bringing  disease  or  death.  Hence  the  many  superstitious  practices 
resorted  to  for  deceiving  or  warding  off  the  evil  spirits.  The  priests 
recite  incantations,  paper  money  is  burned,  and  the  pantagram  is  hung 
over  the  doorway.  The  demons  are  especially  fond  of  marring  beautiful 
children,  hence  the  parents  invent  disgusting  names  for  their  offspring 
in  the  hope  of  misleading  these  tormentors.  Boys  are  especially  liable 
to  injury  at  the  devils'  hands.  Hence  a  guest  never  inquires  into  the 
sex  of  a  newborn  child,  and  a  boy  is  often  dressed  as  a  girl  and  called 
by  a  female  name. 

The  Chinese  physician  is  quite  a  different  individual  from  the  Taoist 
priest,  although  magic  and  astrology  are  inextricably  bound  in  with  his 
theories  of   the  human   organism. 

The  first  authority  on  medicine  in  China  was  the  Emperor  Chen  Long, 
who  lived  about  27.37  B.  C,  and  made  a  classification  of  some  hundred 
medicinal  plants.  A  later  emperor  wrote  up  medical  science  so  far  as 
it  had  progressed  in  2637  B.  C.  In  the  earlier  ages  there  was  some 
jjrogress  in  anatomy,  but  for  the  last  one  thousand  years  at  least,  there 
has  been  practically  no  advance.  The  profound  respect  for  the  dead  has 
interfered  with  dissectintj  and  the  performing  of  autopsies.  Again  there 
is  no  cooperation  between  doctors  and  no  medical  organization.  The  so- 
called  Imperial  Academy  of  Medicine  at  Peking  has  no  jurisdiction  over 
physicians  in  other  parts  of  the  country.  It  is  composed  of  the  phy- 
sicians to  the  emperor.  They  give  instruction  to  the  younger  members 
in  the  medical  classics.  Generally  speaking  the  practice  of  medicine 
is  unlicensed.  Most  doctors  receive  their  library  from  a  father  or  rela- 
tive who  also  imparts  the  secret  remedies  on  which  his  reputation  was 
established.  During  his  apprenticeship  the  young  doctor  diligently 
studies  the  classical  books  and  practices  palpation  of  the  pulse.  The 
doctor  is  called  upon  only  for  more  serious  maladies.  For  the  simpler 
complaints  home  remedies  and  the  formulas  of  old  women  are  used. 
In  times  of  war  the  Chinese  soldiers  attend  to  their  own  wounds.  Adver- 
tisement is  quite  ethical  and  the  office  of  a  doctor  may  be  recognized  by 
the  tablets  displayed  about  the  entrance,  on  which  the  skill  of  the 
physician  is  testified  to  in  high-sounding  phrases.  These  testimonials  are 
usually  signed  and  presented  to  the  doctor  by  grateful  patients.  The 
name  of  the  doctor  is  of  great  importance,  thus  one  hears  of  Dr.  "Eoot- 
of -Strength, "  Dr.  "Khubarb"  and  Dr.  "Salts  of  Hartshorne." 

As  one  would  suspect  from  the  absence  of  dissection  and  the  experi- 
mental methods,  the  Chinese  conception  of  physiology  and  anatomy  is 
fanciful   to    the    extreme.      The   bodv   is    said   to   be    divided   into    three 


168  TEOPICAL  SURGERY  AND  DISEASES 

parts:  (1)  tlie  upper  or  lieadj  (2)  the  middle  or  chest;  and  (3)  the  lowe'f 
part,  or  abdomen,  and  lower  extremities.  Life  depends  on  the  equilibri- 
um of  the  "yang"  and  the  "yin. "  It  is  but  one  manifestation  of  the 
universal  life.  The  body  is  the  microcosm,  the  universe  the  macrocosm. 
The  "yang"  is  the  warm  principle,  actively  flowing.  The  "yin"  is 
the  moist  principle  passively  flowing.  As  the  whole  order  of  the  uni- 
verse results  from  the  perfect  equilibrium  of  these  two  forces,  so  the 
health  of  man  depends  upon  their  equilibrium  in  the  body.  If  the 
"yang"  or  active  principle  predominates,  there  is  excitation;  if  the 
"yin"  or  passive  principle  predominates,  there  is  depression  of  the 
organism.  The  action  of  these  two  forces  manifests  itself  through  eleven 
organs:  the  heart,  liver,  lungs,  spleen,  left  kidney,  large  and  small  intes- 
tines, stomach,  gall  bladder,  urinary  bladder,  and  right  kidney.  The 
lungs  are  divided  into  four  large  and  two  small  lobes.  The  larynx  passes 
directly  into  the  heart,  which  is  the  organ  of  thought,  together  with 
the  spleen.  The  liver  has  seven  distinct  divisions.  The  gall  bladder  is 
the  seat  of  courage.  The  urine  p'asses  directly  from  the  small  intes- 
tines into  the  urinary  bladder  through  the  ileocecal  valve.  The  brain 
and  spinal  marrow  produce  the  semen  which  passes  directly  into  the 
testicles.  There  are  said  to  be  three  hundred  and  sixty-five  bones  in 
the  body. 

Functionally  the  viscera  are  divided  into  two  groups  known  as  the 
six  viscera  in  which  the  "yang"  resides,  and  the  five  viscera  in  which 
the  "yin"  resides.  The  first  group  is  composed  of  the  gall  bladder, 
stomach,  small  intestine,  large  intestine,  bladder,  and  left  kidney,  with 
its  three  heat  centers  the  three  lumbar  sympathetic  ganglia.  The  five 
viscera  are  the  heart,  liver,  lungs,  spleen,  and  right  kidney.  The  dia- 
phragm is  placed  beneath  the  heart  and  luags,  and  covers  over  the 
intestines,  spine,  and  stomach.  It  is  an  impervious  membrane  and 
covers  over  the  foul  gases,  not  allowing  them  to  rise  into  the  heart 
and  lungs.  The  stomach,  spleen,  and  small  intestines  are  the  digestive 
organs.  They  prepare  the  blood  which  is  received  by  the  heart  and  set 
in  motion  by  the  lungs.  The  liver  and  gall  bladder  filter  out  the  various 
humors.  The  lungs  expel  the  foul  gases.  The  kidneys  filter  the  blood, 
while  coarser  material  is  evacuated  by  the  large  intestines.  The  "yang" 
which  is  of  subtle  nature  has  a  constant  tendency  to  rise.  The  "yin" 
which  occupies  the  brain  and  vertebral  column,  as  well  as  the  five  viscera, 
tends  to  descend. 

Each  of  the  organs  has  a  canal  whereby  it  communicates  with  other 
organs.  Thus  the  liver,  kidney,  and  spleen  are  connected  with  the  heart 
by  special  vessels  and  the  vas  deferens  arises  from  the  kidney.  Some 
of  these  communicating  channels  end  in  the  hands  and  some  in  the 
feet.  One  of  the  vessels  in  the  little  finger  is  used  to  determine  the 
nature  of  infantile  diseases.  Six  of  these  vessels  carry  the  "yang"  and 
six  carry  the  "yin. "  These  two  forces  are  disseminated  through  the 
whole  organism  by  means  of  the  gases  and  the  blood.  The  former  act 
upon  the  latter  as  the  wind  upon  the  sea.     The  interaction  of  these  two 


OBSERVATIONS    ON    CHINA  169 

as  they  circulate  in  the  vessels  produces  the  pulse.  The  blood  makes 
a  complete  circulation  of  the  body  about  fifty  times  in  twenty-four  hours. 
In  these  fifty  revolutions  the  blood  passes  twenty-five  times  through 
the  male  channels  or  those  of  the  active  principle  and  twenty-five  times 
through  the  female  channels  or  those  of  the  negative  principle.  The 
blood  is  said  to  return  to  its  starting  place  once  in  every  half  hour, 
instead  of  once  in  twenty-five  seconds,  according  to  modern  physiolo,gists, 
having  traversed  a  course  of  some  fifty-four  meters. 

Each  organ  is  related  to  an  element:  fire  rules  the  heart,  metal  the 
lungs,  etc.  There  is  likewise  a  close  relationship  to  the  planets,  to 
season,  color,  and  taste.  This  interrelationship  is  well  illustrated  by 
the  following  table: — 


Organ 

Planet 

Element 

Color 

Taste 

Stomach 

Saturn 

Earth 

Yellow      • 

Sweet 

Liver 

Jupiter 

Wood 

Green 

Sour 

Heart 

Mars 

Fire 

Red 

Bitter 

Lungs 

Venus 

Metal 

White 

Sharp 

Kidney 

Mercury 

Water 

Black 

Salt 

Auscultation  and  percussion  are  wholly  unknown  as  diagnostic  aids 
to  the  Chinese  physician.  Entire  reliance  is  placed  on  palpation  of  the 
pulse  and  the  general  facies  of  the  patient  in  making  the  diagnosis. 
The  taking  of  the  pulse  is  almost  like  a  solemn  rite. 

The  pulse  may  be  palpated  at  eleven  different  points,  as  follows: — 
Radial,  cubital,  temporal,  posterior,  auricular,  pedal,  posterior  tibial,  ex- 
ternal plantar,  precordial,  and  in  three  places  over  the  aorta.  Usually, 
however,  the  physician  is  satisfied  with  the  palpation  of  the  pulse  of  the 
right  and  left  wrist.  With  the  right  hand  he  feels  the  left  pulse  and 
with  the  left  hand  the  right  pulse.  He  applies  three  fingers, — the  ring, 
middle  and  index  finger  over  the  pulse  and  the  thumb  underneath  the 
wrist.  Then  he  palpates  the  pulse  with  each  finger  successively.  Under 
the  ring  finger  the  pulse  of  the  right  hand  reveals  the  condition  of  the 
lung,  middle  of  chest,  and  large  intestines,  while  in  the  left  hand  the 
ring  finger  determines  the  state  of  the  heart  and  the  small  intestines. 
The  pulse  under  the  middle  finger  corresponds  on  the  right  to  the  condi- 
tion of  the  stomach  and  spleen,  on  the  left  to  the  state  of  the  liver  and 
gall  bladder.  The  index  finger  placed  over  the  pulse  of  the  right  radial 
shows  the  condition  of  the  bladder  and  the  lower  portion  of  the  body, 
over  the  left  radial  it  reveals  the  state  of  the  kidneys  and  ureters.  For 
each  of  these  six  pulses  the  physician  must  practice  weak,  moderate, 
and  strong  pressure,  to  determine  whether  the  pulse  be  superficial,  mod- 
erate, or  deep.  This  must  be  done  during  nine  complete  inspirations. 
If  the  pulse  be  rapid  the  "yang"  principle  is  predominant,  if  slow,  the 
"yin"  is  predominant.  There  are  twenty-four  main  varieties  of  pulse. 
The  Chinese  physician  must  be  trained  to  palpate  the  pulse  so  skillfully 
that  by  this  single  means  the  nature  of  diseases  and  even  the  months 
of  gestation  in  a  pregnant  woman  may  be  determined.  Ten  or  more 
minutes  must  be  spent  in  the  palpation  of  the  pulses. 

Sometimes  a  Chinese  physician  will  consider  other  factors.     For  ex- 


170  TROPICAL    SURGERY    AiSTD    DISEASES 

ample,  it  is  said  that  by  cxaraination  of  the  tongue  thirty-six  symptoms 
may  be  diagnosed  according  as  tlie  tongue  is  white,  yellow,  blue,  red,  or 
black,  and  depending  on  the  extent  of  the  coating.  From  the  general 
appearance  of  the  face  and  nose  the  state  of  the  lungs  may  be  discovered. 
Examination  of  the  eyes,  orbits,  and  eyebrows  shows  the  condition  of 
the  liver.  The  cheeks  and  tongue  vary  with  the  state  of  the  heart,  the 
end  of  the  nose  with  the  stoma cli.  The  ears  suggest  the  conditions  of 
the  kidneys;  the  mouth  and  lii^s  the  state  of  the  spleen  and  stomach. 
The   color  and  figure   of  the  patient   also   count  in   a   diagnosis. 

Diseases  are  spoken  of  as  internal  and  external.  External  cases  are 
those  apparent  on  the  surface,  such  as  all  skin  affectations,  tumors  grow- 
ing on  the  surface  and  of  late  all  surgery  has  been  classified  as  the 
practice  of  external  diseases.  Internal  diseases  include  all  fevers  and 
diseases  of  the  heart,  Iniigs,  and  abdominal  organs.  More  specifically 
diseases  are  classified  under  nine  heads  as  follows:  (1)  Affections  of 
the  great  blood  vessels,  including  smallisox;  (2)  diseases  of  the  lesser 
blood  vessels;  (3)  fevers;  (4)  female  complaints;  (5)  cutaneous  dis- 
eases; (6)  conditions  requiring  acupuncture;  (7)  diseases  of  the  throat, 
mouth,   and  teeth;    (8)    diseases  of  the  bones;    (9)    affections   of  the  eye. 

Diseases  are  said  to  be  produced  by  internal  and  external  agents. 
Among  the  external  diseases  are:  (I)  wind,  which  causes  headache  or 
apoplexy,  dizzin'ess,  chapping  of  face,  diseases  of  the  eye,  ear,  nose, 
tongue,  teeth,  etc.;  (2)  cold  may  cause  cough,  cholera,  heart  pains, 
rheumatism,  and  abdominal  pains;  (3)  heat  causes  chills  and  diai'rhea ; 
from  dampness  comes  constipation,  distention  of  abdomen,  watery 
diarrhea,  gonorrhea,  nausea,  pain  in  kidneys,  jaundice,  anasarca,  pain  in 
small  intestines,  and  pain  in  the  feet;  (5)  from  dryness  come  thirst 
and  constii^ation;  (6)  Fire  causes  pain  in  the  sides,  diabetes,  etc.  The 
diseases  of  internal  origin  are  classified  as  disorders  of  the  gases,  blood, 
sputum,  and  depressed  spirits. 

The  treatment  of  disease  by  the  Chinese  doctor  consists  chiefly  in 
the  administration  of  drugs.  Surgery  has  been  an  unknown  art.  Re- 
cently two  charitable  institutions  have  been  established  in  Canton  for 
the  treatment  of  the  sick  according  to  native  methods  of  practice.  At 
one  of  these  so-called  hospitals  I  was  informed  that  bullets  were  re- 
moved by  placing  a  kind  of  plaster  at  the  wound  of  entrance.  The  ingre- 
dients of  the  plaster  have  a  remarkable  magnetic  power  over  the  embedded 
bullet  and  gradually  draw  it  out  through  the  same  opening  by  which  it 
entered.  My  informant  had  never  seen  this  line  of  treatment  actually 
carried  out,  however. 

Perhaj)s  in  no  line  does  the  native  j)ractitioner  show  his  ignorance 
more  than  in  the  treatment  of  fractures.  Xo  attempt  is  made  to  reduce 
the  parts.  A  special  clay  is  placed  in  a  wooden  bowl.  The  heads  of 
several  chickens  are  cut  off,  while  incantations  are  repeated  and  the 
blood  is  allowed  to  flow  on  the  clay  in  the  bowl.  Blood  and  clay -are 
now  mixed  together  and  applied  to  the  fractured  extremity.  Bandages 
are  used  to  bind  on  thin  strips  of  bamboo.     When  the  last  turn  of  the 


OBSERVATIONS    ON    CHINA  171 

bandage  is  being  wound   on,  the  blood   of   another  chicken    is   poured   on. 

The  only  real  oiieration  performed  by  the  Chinese  is  the  castration  of 
tlic  eunuch,  and  castration  as  a  penalty  for  adultery.  With  one  sweep  of 
a  sharp  knife  the  genital  organs  are  completely  removed  on  a  level  wjtli 
the  skin  of  the  ]iubis.  A  metal  plug  is  inserted  in  the  urethral  opening 
and  a  cloth  wrung  out  of  cold  water  is  a])]died  to  the  bleeding  surface  and 
firmly  bound  on.  The  patient  is  allowed  to  drink  no  water  for  three 
days  when  the  dressing  is  removed,  the  plug  withdrawn  and  the  i)atient 
allowed  to  urinate. 

Coming  now  to  the  real  field  of  the  Chinese  doctor  we  find  that  the 
number  and  variety  of  remedies  recommended  by  the  Chinese  Materia 
Medica  can  only  be  compared  to  our  own  National  Pharmacopeia.  The 
great  Materia  Medica  compiled  in  the  16th  century  is  composed  of  52 
books  and  contains  1892  remedies.  Kipling's  verse  applies  to,_the  Chinese 
as  to  the  British  people  for  whom  he  wrote  it: 

"Alexanders   and  Marigold, 

Eyebright,  Orris,  and  Elecampane, 

Basil,  Eocket,  Valerain,  Eue, 

(Almost   singing   themselves   they   run) 

Vervain,  Dittany,  Call-me-to-you, 

Cowslip,  Melilot,  Eose  of  the  Sun, 

Anything  green  that  grew  out  of  the  mould. 

Was  an  excellent  herb  to  our  fathers  of  old. ' ' 

The  drugs  and  other  medicaments  are  weighed  out  according  to  a 
decimal  system  as  follows: 

1  tael  or   leung          ec^uals  40.00     gm. 

1  tsin                                  "  4.00     gm. 

1  fan                                   ' '  .4       gm. 

1  lei                                     "  .04     gm. 

1  ho                                     "  .004  gm. 

Often  a  prescription  is  given  because  of  the  resemblance  of  the  drug 
to  the  organ  affected.  Thus  for  renal  diseases,  haricot  or  kidney  beans 
are  given.  Minerals  are  administered  as  salts.  Plants  are  used  in  the 
form  of  roots,  stems,  leaves,  flowers,  and  dried  fruits.  The  bones  of  a 
tiger  are  frequently  ground  up  and  given  to  a  debilitated  person.  The 
grasshopper  is  dried  and  used  as  a  medicine  and  the  shells  of  the  cicada 
are  collected  from  the  bark  of  trees  and  mixed  with  other  ingredients. 
Tinctures  and  extracts  are  prepared  from  rice  wine.  Pills  are  often 
made  with  a  thick  shell  of  paraffine  which  is  broken  off  and  the  contents 
chewed  up.  Various  forms  of  pilasters  and  blisters  may  be  applied  to 
the  skin.     The  actual  cautery  is  often  used  as  a  revulsive. 

Among  the  pills  the  best  are  the  "Wai  Shaang  Uen"  or  life-preserv- 
ing pills  costing  about  a  dollar  apiece.  They  are  comi)Osed  of  Man- 
churian  ginseng,  deer's  horns,  and  other  drugs.  Among  other  common 
remedies  may  be  named  dried,  powdered  rattlesnake  skins,  the  bile  of 


172  TROPICAL  SURGERY  AND  DISEASES 

the  ox  and  dog  for  jaundice,  dried  shrimps,  etc.  Quicksilver  is  often 
poured  into  gunshot  wounds  in  order  to  dissolve  the  bullet.  In  some  drug 
shops  two  signs  are  hung  at  the  entrance;  on  one  are  written  the  names  of 
venereal  diseases,  on  the  other  such  diseases  as  hemorrhoids,  wounds, 
ulcers,  etc.  The  patient  explains  in  which  class  his  disease  belongs  and 
is  promptly  given  the  appropriate  remedy.  Among  the  most  used  drugs 
are  some  that  are  found  in  the  western  pharmacopeias;  viz.,  ginseng, 
rhubarb,  sulphur,  pomegranate  root,  aconite,  opium,  arsenic,  and  mercury. 

Diseases  of  the  liver  and  eyes,  which  are  sympathetic  organs,  are 
cured  by  giving  pork's  liver.  In  Kwangtung  Province  human  blood  is 
considered  an  excellent  remedy  and  at  executions  people  may  be  seen 
collecting  the  blood  in  little  vials.  It  is  then  cooked  and  eaten.  A 
genuine  prescription  written  by  a  physician  to  be  used  as  a  laxative 
was  composed  of  rumex  hydrolepathium,  quercus  glauca,  sodium  sulphate, 
and  magnolia  hypoleuca.  The  parts  from  these  plants  are  boiled  with 
the  sodium  sulphate  and  the  "tea"  is  drunk  by  the  patient. 

A  remedy  which  I  have  not  infrequently  seen  applied  to  a  patient 
in  extremis  is  as  follows:  A  rooster  is  killed  and  the  body  is  cut  in 
half,  longitudinally,  and  the  bleeding  half  is  quickly  applied  to  the  skin 
of  the  patient 's  abdomen.  If  there  is  any  possibility  of  cure  this  is 
supposed  to  be  infallible. 

The  use  of  the  acupuncture  needle  seems  to  be  seldom  resorted  to  in 
the  neighborhood  of  Canton.  The  theory  on  which  it  is  based  is  that  if 
one  punctures  the  blood  vessels  connecting  different  organs  the  disease 
will  be  aborted.  Three  hundred  and  eighty-eight  points  suitable  for 
acupuncture  are  described.  There  is  a  manikin  at  Peking  pierced  with 
holes  at  all  the  points  suitable  for  acupuncture.  Paper  is  pasted  over  it 
and  students  learn  to  find  the  proper  holes  through  the  paper.  The 
needles  vary  from  1%  to  28  cm.  in  length  and  are  made  of  gold,  silver, 
or  steel.  During  the  operation  the  patient  coughs  and  the  errant  humors 
are  directed  back  into  their  normal  courses. 

Such  in  brief  is  medicine  as  it  is  practiced  by  the  Chinese  doctor  of 
today.  One  is  reminded  of  the  old  humoral  theory  of  Europe  in  the 
Middle  Ages.  But  modern  education  in  China  has  brought  a  new  light 
to  the  people  and  in  all  the  large  cities  and  many  of  the  small  ones, 
Western  medicine  is  slowly  but  surely  winning  its  way. 


JAPAN 

Medical  education  in  Japan  was  founded  by  German 
teachers  about  thirty-five  years  ago.  The  official  language 
for  medicine  and  allied  sciences  was  German,  which  is 
used  to  a  considerable  extent  today.  About  twelve  years 
ago  the  last  of  the  foreign  teachers  were  replaced  by 
Japanese. 


OBSERVATIONS    OX    JAPAN  173 

The  place  Japanese  medical  scientists  have  taken  in 
the  world  needs  no  comment  except  perhaps  to  call  atten- 
tion to  the  brief  period  in  which  it  has  been  attained  as 
an  evidence  of  the  immense  value  of  a  definite  prear- 
ranged plan,  carried  out  to  the  letter.  This  shows  in  all 
phases  of  their  national  development  and  in  medicine  even 
as  early  as  1900  when  the  Japanese  medical  corps  in  the 
army  at  Pekin  was  superior  to  that  of  any  other  nation. 
Their  victory  over  Russia  in  1904-1905  was  a  victory  of 
the  extreme  scientific  efficiency  of  a  small  army  over 
enormous  odds  in  men  and  money  in  an  army  in  which 
such  methods  were  wanting;  the  medical  corps  of  the 
Japanese  army  b}^  prearrangement  guaranteed  against 
the  loss  of  men  by  disease  and  was  the  main  factor  in  the 
success  of  their  arms. 

The  influence  of  modern  medicine,  applied  entirely  by 
Japanese,  on  the  national  health  and  welfare  is  one  of  the 
chief  sources  of  her  strength  and  is  her  guarantee  against 
decadence.  In  these  respects  she  is  far  ahead  of  other 
nations,  some  with  centuries  of  history  behind  them,  and 
Japan,  after  less  than  forty  years  development  from  a 
chaotic  condition,  is  held  up  as  a  model  they  must  follow 
or  suffer  the  consequences.  The  weak  point  in  her  med- 
ical educational  system  is  her  second  grade  medical 
schools  whose  preliminary  educational  requirements  are 
those  of  the  middle  public  schools  which  have  three  years 
less  work  than  the  higher  schools  from  which  one  can 
enter  the  university  medical  school.  Admission  to  the 
second  grade  medical  school  is  by  competitive  examina- 
tion which  is  rather  strict,  but  Chinese  are  admitted  with 
no  condition  other  than  that  of  being  able  to  speak 
Japanese. 

The  Surgery  of  Japan 

Several  years  ago  Professors  Scriba  (German),  Sato, 
and  Kundo,  surgeons  of  the  Imperial  University  of  Tokyo, 


174  TROPICAL    SURGERY    AXD    DISEASES 

informed  me  that  the  immber  of  leg  and  foot  ulcers  was 
very  large  but  no  cases  of  Madura  foot  had  been  seen; 
that  in  former  years  there  was  a  great  deal  of  syphilis  in 
Japan  and  also  considerable  venereal  disease;  that  beri- 
beri is  common  among  the  young,  strong,  and  healthy; 
that  cancer,  except  of  the  skin,  is  common;  that  surgical 
tuberculosis  and  other  chronic  surgery  occurs  in  about 
the  same  percentage  as  in  Europe  and  that  their  general 
results  are  good.  The  only  surgical  condition  they  con- 
sidered peculiar  to  Japan  they  called  "Kakke"  and  had 
made  it  the  subject  of  special  researches.  It  is  an  acute 
suppurating  myositis,  ushered  in  by  fever,  followed  in 
three  or  four  days  by  deep  and  superficial  furunculosis 
which  later  developed  into  large  intramuscular  abscesses. 
Under  drainage  these  abscesses  heal  and  the  loatients 
usually  recover  completely  in  uncomplicated  cases.  The 
result  of  the  investigations  into  the  specific  microbic 
cause  and  source  of  infection  had  not  been  determined. 

THE  PHILIPPINES 

The  natives  of  the  Philippine  archipelago  belong  to  the 
Malay  race,  and  while  there  are  very  few  pure  Malays 
among  the  leaders,  the  stock  has  been  improved  by  the 
admixture  of  other  blood  especially  that  of  the  Chinese. 
They  are  the  most  enlightened  and  vigorous  branch  of  the 
Malays,  have  been  Christians  for  centuries,  and  are  near- 
est akin  to  Europeans  in  tliought  and  aspirations  of  any 
alien  race.  They  are  eager  to  learn  all  that  can  be  im- 
parted, and  have  evinced  such  intelligent  capacity  that 
their  rapid  progress  in  the  art  of  self-government  and 
their  universal  desire  for  education  should  appeal 
strongly  to  American  sympathy. 

As  in  other  Oriental  countries,  the  efficiency  of  the 
natives  is  enormously  decreased  by  chronic  curable  dis- 
ease, but  their  salvation  in  this  respect  can  not  be  assured 


OBSEHVATJONS    ON    THE    PJilLlPPlNES  175 

until  a  competent  body  of  native  medical  men  is  devel- 
oped. There  are  two  medical  schools;  one  a  government 
and  one  a  church  school.  Premedical  and  medical  educa- 
tion is  now  well  established  in  the  government  school 
only;  the  students  are  earnest,  studious,  intelligent,  and 
hard  working.  The  Filipino  women  hold  a  very  high  posi- 
tion of  influence  for  good,  and  their  force,  dignity,  and 
strength  of  character  are  striking.  The  aptitude  of  the 
younger  women  for  nursing  and  the  medical  profession 
will  be  of  enormous  value  to  their  race  in  solving  its 
physical  problems.  The  principal  diseases  are  due  to 
malaria,  tuberculosis,  and  intestinal  parasites.  The  epi- 
demics of  cholera,  plague,  and  smallpox  have  been 
brought  under  control  for  a  time  at  least  by  the  splendid 
work  of  the  American  Department  of  Health,  but  so  far 
no  impression  has  been  made  on  the  more  important  tu- 
berculosis, malarial,  or  intestinal  diseases,  and  none  will 
be  until  education  in  health  matters  is  further  advanced 
and  a  large  body  of  trained  native  medical  men  is  created. 
There  are  less  than  500  doctors  for  the  population  of  eight 
million,  one  to  each  20,000  of  the  population  or  one  to 
each  420  square  miles  of  territory,  and  of  these  over  250 
are  in  the  city  of  Manila. 

Although  next  to  police  and  fire  protection,  the  health 
of  the  people  was  the  most  crjdng  need  of  the  Philippines, 
it  was  eight  years  after  the  Americans  took  over  the  gov- 
ernment of  the  Islands  before  they  recognized  the  desira- 
bility of  public  medical  institutions  or  medical  education 
in  any  but  an  academic  way.  The  only  medical  organiza- 
tion supported  by  public  funds  during  this  period,  outside 
of  board  of  health  work,  was  one  to  care  for  high  officials, 
their  families  and  those  dependent  upon  them;  this  was 
later  extended  to  include  all  employees  of  the  govern- 
ment and  their  families. 

Medical  education  is  making  poor  progress  in  the 
Philippines  and  will  not  improve  until  a  new  start  is  made. 


176  TROPICAL    SURGERY   AND    DISEASES 

The  government  must  formally  recognize  its  health  prob- 
lems and  commit  itself  to  a  program  that  will  ultimately 
solve  them.  Several  thousand  competent  native  medical 
men  are  needed.  The  profession  of  medicine  and  public 
health  must  be  made  attractive  to  students  by  the  found- 
ing of  numerous  scholarships  and  the  creation  of  a  de- 
partment of  public  health  in  which  there  is  a  future  for 
ambitious  men.  The  present  organization  of  the  govern- 
ment university  medical  school  and  hospitals  is  ideal 
only  so  far  as  its  plan  on  paper  is  concerned.  It  has 
broken  down  through  lack  of  direction  which  could  or- 
ganize the  independent  and  discordant  elements  into  a 
harmonious  whole.  There  is  no  real  cooperative  clinical, 
teaching,  and  hospital  organization,  no  true  spirit 
founded  on  the  correct  and  practical  philosophy  and 
psychology  which  should  saturate  from  above  downwards 
each  worker,  unit,  institution,  and  student,  without  which 
adequate  public  support  and  pride  in  the  institutions 
can  not  be  expected.  Foreign  medical  men  selected  with 
great  care  as  teachers,  who  from  the  ordinary  standpoint 
were  the  best  trained  and  equipped  men  available,  are 
too  often  failures  because  no  attention  is  paid  to  prepar- 
ing them  to  accept  things  as  they  find  them,  to  lay  aside 
their  prejudices  and  to  cultivate  a  real  sympathy,  under- 
standing, and  aptitude  for  the  native  problems.  The 
church  medical  school  has  a  far  lower  standard  than 
ordinary  minimum  educational  requirements  demand. 
This  school  graduates  more  men  and  perpetuates  a  double 
standard  medical  hodj  which  will  be  fatal  to  true  prog- 
ress. The  teaching  is  entirely  in  Spanish  with  no  bilin- 
gual requirements,  which  is  a  mistake,  even  though  all 
medical  literature  is  readily  translatable  into  the  Spanish 
idiom.  It  will  take  a  longer  time  to  teach  in  English, 
but  the  best  results  for  the  Filipino  people  and  their  fu- 
ture medical  xorofession  will  be  attained  in  the  end. 
A  subject  for  consideration  for  Filipino  complacency 


OBSERVATIONS    ON    THE    PHILIPPINES  177 

is  that  if  they  expect  to  progress  and  retain  what  has  been 
accomplished  for  them,  they  can  do  so  only  by  following 
the  example  of  Japan  in  her  university  medical  education 
and  never  replace  a  foreign  teacher  with  a  native  until  the 
native  has  proved  his  ability  to  fill  the  position  by  some- 
thing more  than  political  influence  enough  to  get  the  job. 
Japan's  secondary  medical  school  system,  however,  is 
something  to  be  avoided.  Since  the  Philippine  govern- 
ment medical  school  ojDened  in  1907,  about  one  hun- 
dred degrees  in  medicine  have  been  granted  and  at  a  cost 
of  over  $150,000  a  year.  There  has  been  a  lack  of  real 
apjDreciation  of  the  imperative  needs  for  modernly  edu- 
cated native  medical  men  so  far  as  any  efficient  practical 
method  to  meet  these  needs  is  concerned,  such  as  the 
stimulating  of  students  to  enter  the  profession.  At  least 
one  hundred  graduates  a  year  from  the  university  school 
alone  should  have  been  going  out  by  the  end  of  1917,  and 
the  standard  of  the  Spanish  school  could  have  been  raised, 
had  the  forces  and  influences  at  the  command  of  the  gov- 
ernment been  put  in  motion  to  this  end.  As  at  present 
conducted,  it  would  be  far  better  and  more  economic  to 
send  the  government  school  students  to  the  United 
States  for  the  last  two  years  of  the  five  year  course ;  this 
would  give  them  the  best  methods  of  clinical  teaching, 
the  high  ideals  of  modern  institutional  work  and  a  use  of 
the  English  language  Avhich  they  are  not  getting  now; 
something  that  they  could  take  home  and  apply  in  the 
continuation  of  their  education  in  their  home  hospitals 
to  the  great  advantage  of  those  institutions  as  well  as  to 
the  cause  of  medical  education.  In  addition,  there  should 
be  established  "a  material  betterment"  fund  to  send 
abroad  at  stated  intervals  deserving  young  men,  teachers 
and  institutional  men  for  the  i3urposes  of  observation  and 
study.  There  is  no  reason  why  the  Filipinos  should  not 
take  high  place  in  the  medical  world  in  less  than  thirty 


178  TROPICAL    SUJIGERY    AXD    DISEASES 

years,  but  everything  depends  upon  adherence  to  a  wise 
and  comiDrehensive  general  plan. 

As  a  si3ecific  example  of  general  conditions  in  the 
Philippines,  note  the  following  abstract: 

A  Medical  Survey  of  a  Typical  Filipino  Country  Town 
of  6000  Inhabitants 

In  1909  a  body  of  medical  school,  health  department, 
and  laboratory  men  spent  three  months  on  a  medical  sur- 
vey of  Taytay,  a  town  of  60(30  persons,  that  had  suf- 
fered severely  from  epidemics  in  the  past  and  was  known 
to  be  an  average  insanitary  country  town.  The  survey 
was  under  the  direction  of  Dr.  P.  E.  Garrison,  United 
States  Xavy,  who  suggested  the  idea,  and  the  scheme 
might  furnish  a  working  model  for  other  tropical  coun- 
tries. The  work  was  done  by  volunteers  during  the  sum- 
mer vacation  and  at  very  small  expense. 

The  water  supply  from  wells  was  found  to  be  about 
as  undesirable  as  possible  for  community  health,  but  the 
ground  was  promising  for  drilling,  and  an  artesian  flow 
has  since  been  secured.  The  bacteriologic  analysis  of  the 
drinking  water,  made  by  Clegg,  showed  from  500  to  12,030 
bacteria  per  cubic  centimeter,  also  bacillus  communis, 
vibrios,  amebas  and  flagellata,  while  the  chemical  analysis 
showed  high  chlorine  figures  with  an  excess  of  nitrogen  in 
all  its  forms. 

The  principal  food  supplies  used  were  almost  entirely 
local.  Eice  was  the  basis  of  the  meal  and  fish,  both  fresh 
and  dried,  was  the  second  most  common  food.  Pork,  the 
only  meat,  was  for  sale  on  market  days;  chickens  and 
ducks  were  abundant  and  eggs  both  fresh  and  incubated 
(bolut)  were  somewhat  used  by  the  well-to-do  classes; 
various  prepared  foods  were  on  sale  consisting  mostly 
of  rice  and  sugar;  also  Chinese  foods  of  seaweeds,  a 
spaghetti   and  mongo   beans;   wheat,   milk,   butter   and 


OLiSEItVATIOXS    ON    Till-;    IM 1  llJiTKXES  179 

cheese  had  no  ])lacc  in  ilic  dietary;  t^vellty-five  fresh  fruits 
were  to  be  had  l)iil  only  the  bananas,  mang'oes,  and  pine- 
apjDles  are  first-chiss  from  an  edible  standi)oint;  over 
twenty  vegetables  were  available  but  were  very  inferior 
and  most  of  them  Avere  in  limited  quantities;  of  pot  herbs 
and  condiments  they  had  six  to  eight  varieties  of  each. 
Aron  investigated  their  food  from  a  physiologic  stand- 
point; the  daily  average  amount  of  rice  per  person  was 
found  to  be  700  grams,  equaling  50  grams  of  protein  and 
2000  calories;  fish  to  4-0  grams  of  protein  and  200  calories, 
and  vegetables  equaling  500  calories  or  a  to-tal  of  2700 
calories  for  an  average  person,  all  for  an  average  cost 
of  121/2  centavos  a  day  or  6  cents  in  U.  S.  currency.  In 
a  provincial  town  an  average  native  can  live  very  com- 
fortably on  this  amount,  but  a  hard  working  man  needs 
at  least  25  per  cent  more  food  and  they  are  in  much  bet- 
ter condition  with  more  meat. 

Mosquitoes  and  other  insects  found  by  Banks  were,  18 
species  of  flies ;  bedbugs,  not  common ;  head  lice,  which  are 
abhorred  by  all  Filipinos,  were  universal;  fleas  made  all 
of  the  dogs  miserable  and  occasionally  annoyed  the  na- 
tives; dog  tics  occurred,  also  caraboa  lice  which  seldom 
bother  men.    Ten  varieties  of  mosquitoes  were  detected. 

The  vital  statistics  and  the  general  sanitary  conditions 
were  carefully  worked  out  by  Clements  and  are  very 
interesting;  the  death  rate  was  from  twenty-seven  to 
forty-five  per  thousand. 

Garrison  examined  17  per  cent  of  tlie  ])opulation  for 
intestinal  parasites  and  found  ascaris,  trichui'is,  liook- 
Avorms,  strongyloides,  oxyuris,  ameba,  ciliates,  flagel- 
lates, and  encysted  protozoa;  total  infection  per  thousand, 
182;  intestinal  worms  alone,  172.G. 

Dr.  Bean  investigated  the  racial  anatomy  and  made 
anthropometric  studies. 

Of  789  physical  examinations  made,  558  comiDlained 
of  some  disease;  disease  of  the  nervous  svstem  was  found 


180 


TROPICAL    St^RGERY   AXD    DISEASES 


in  32;  of  the  genitourinary  system,  37;  tnmors,  20;  general, 
20;  alimentary  system,  165;  respiratory,  135. 

Malaria  parasites  were  found  sixteen  times  in  742  indi- 
viduals in  fresh  hlood  smears;  no  relapsing  fever  spiro- 


Fig.    65. — Symmetrical    fibromata     (1909).       (Philippine    Journal    of    Science.) 

chetes  were  found  in  any  of  the  fever  patients  examined. 
Filariasis  searched  for  at  night  Avas  found  once  in  400 
people;  about  1  per  cent  of  800  people  examined  had 
tuberculosis;  4  cases  of  typhoid  were  found;  11  cases  of 
goiter,  all  in  women;  no  beriberi,  due  to  the  use  of  un- 
milled  rice;  venereal  disease  and  syphilis  were  rare. 


OBSERVATIONS    OX    TPIE    PJIILIPIMXES 


181 


Fig.    66. — Symmetrical    fibromata   on   forearms 


(Philippine  Journal  of  Science.) 


id   ankles.      Luzon,    P.    I.,    1909. 


182 


TROPICAL    SURGERY   AXD   DISEASES 


Symmetric  siil)cutaneous  fibromata  were  found  in  about 
3  per  cent  of  women  over  30  years  of  age,  either  on  one  or 
both  ankles  and  elbows ;  sections  showed  them  to  be  pure 
fibromata  and  some  were  calcified.     (Figs.  65  and  66.) 


Fig.    67. — "Fuente,"    showing    ball    of    wax    in    ulcer    for    permanent    counterirritation 
against   all    diseases,    1909.      (Philippine   Journal    of    Science.) 

Twenty-one  cases  of  yaws  were  found  after  a  careful 
search;  several  "Fuente"  cases  were  found.     (Fig.  67.) 

Many  maps,  illustrations,  and  disease  tables  were  made 
and  a  census  Avas  taken.  For  the  complete  report,  see  the 
Philippine  Jounial  of  Science,  1901,  iv,  No.  4. 


CHAPTER  XI 

ANSWERS  TO  A  QUESTIONNAIRE  OF  FIFTY- 
THREE  INQUIRIES  SENT  TO  COUNTRIES 
IN  AND  ABOUT  THE  TROPIC  ZONE 

The  purely  medical  responses  to  the  circular  request 
are  omitted,  but  nmch  of  the  surgical  and  borderline  in- 
formation acquired,  fragmentary  as  it  is,  Avas  considered 
of  sufficient  value  to  edit  somewhat  and  present  without 
apologies.  Some  of  this  material  Avas  published  just  as 
it  was  received,  in  a  Manila  medical  bulletin  which  has 
since  ceased  publication. 

Over  two  thousand  copies  of  this  questionnaire  mailed 
to  medical  workers  in  and  near  the  tropic  zone  in  1911 
brought  a  four  per  cent  response.  This  Avould  have  been 
highly  satisfactory  to  any  commercial  advertiser  be- 
cause second  and  third  ''follow-up"  communications 
would  have  increased  this  percentage  considerably ;  simi- 
lar improvement  could  have  been  expected  had  this  ques- 
tionnaire been  systematically  pressed.  The  most  of  the 
answers,  however,  show  that  the  average  of  medical  men 
and  women  in  and  near  the  equatorial  belt  are  no  bet- 
ter and  no  worse  than  their  brethren  in  other  parts  of 
the  world;  that  about  90  per  cent  of  practitioners  of 
medicine  everywhere,  including  those  in  cities,  do  not 
record  their  observations,  do  not  examine  their  j)atients 
in  any  but  the  most  superficial  way,  have  no  proper  work- 
ing library  of  books  and  current  literatui-e,  or  do  not 
make  their  observations  and  their  reading  availal)h'  to 
themselves  or  to  the  world  l)y  a  simple  system  ol'  in- 
dexing. One  man  who  lias  ])een  higldy  honored  by  his 
country  and  profession  as  a  tropical  authority  since  re- 

183 


184  TROPICAL  SUEGEEY  AND  DISEASES 

turning  home,  replied,  regretting  his  inability  to  answer 
the  questions,  that  although  he  had  resided  in  the  Trop- 
ics for  six  years,  he  had  not  kept  any  notes.  The  few 
good  reports  are  so  perfect  that  they  can  well  serve  as 
models  to  those  tropical  workers  ambitious  to  be  of  real 
service  to  the  world  and  to  medical  science. 

Those  readers  whom  these  reports  will  interest,  Avill 
find  much  to  reflect  on,  as  to  the  presence  of  certain  dis- 
eases in  one  place  and  their  entire  absence  or  infre- 
quency  in  another,  on  the  ditferences  in  type  and  severity 
in  countries  on  the  same  lines  of  travel  and  on  the  evi- 
dent fact  that  diseases  kno^\m  to  be  due  to  certain  mi- 
crobic  organisms  vary  greatly  in  different  parts  of  the 
Avorld.  In  a  disease,  for  instance,  which  is  clinically 
chronic  syphilis,  gives  the  specific  serologic  reaction  and 
^delds  promptly  to  antiluetic  therapy,  no  treponema  of 
any  sort  is  discoverable  and  no  primary  syphilis  de- 
velops amoiig  the  natives  or  foreigners ;  the  same  dis- 
ease with  a  treponema  in  another  country  manifests  it- 
self very  rarely  in  the  late  forms,  but  is  frequently  seen 
in  its  primary  and  secondary  stages.  Enough  was 
gained  by  this  effort  perhaps  to  warrant  a  more  system- 
atic and  sustained  attempt  to  acquire  such  data.  Such 
an  endeavor  to  be  successful  should  be  undertaken  by 
the  American  Societ}^  of  TroiDical  Medicine,  as  the  older 
tropical  organizations,  it  seems,  can  not  be  interested  in 
problems  outside  of  their  own  colonies. 

Races,  Physical  Conditions,  Food  and  Habits 

American  Samoa  (Cottle.^) — American  Samoa  is  situ- 
ated 14°  South  of  the  equator.  The  temperature  is  very 
equable,  there  being  a  difference  of  only  two  or  three  de- 
grees between  day  and  night  and  of  only  eight  or  ten  de- 
grees between  summer  and  winter.  The  rainfall  is  often 
more  than  275  inches  in  tlie  year,  yet  the  degree  of  humid- 
ity is  seldom  high  enough  to  affect  the  health.     The  na- 


ANSWERS    TO    QUESTlONNAlPtE  185 

tives  are  of  the  same  race  as  the  Maori  of  New  Zealand 
and  the  HaAvaiian  of  the  Sandwich  Islands.  Abont  7000 
natives,  and  100  Europeans  live  so  isolated  from  the 
world— three  da^^s  of  steaming  from  their  nearest  neigh- 
bors— so  unaffected  even  by  temporary  contact  with 
other  races,  that  they  are  remarkably  free  from  the  com- 
mon contagious  and  infectious  diseases  that  exist  in  most 
places  in  the  world.  The  iiative  eats  the  cocoanut,  ba- 
nana, bread  fruit,  and  taro,  a  vegetarian  diet,  yet  one 
which  gives  him  health  and  strength  and  endurance  Avell 
above  the  average.  Fish,  pork,  and  salt  meats  are  the 
occasional  luxuries  added  in  times  of  feasting. 

An  amount  of  physical  labor  equivalent  to  about  five 
hours  a  week  will  bring  the  individual  practically  all 
his  personal  necessities,  but  his  hospitable  tastes,  further 
fostered  by  elaborate  marriage,  birth,  and  death  customs 
force  the  easy-going  leisure  loving  Samoan  to  hard  work 
and  these  demands  on  his  energy  keep  him  vigorous, 
robust,  and  well-developed.  He  can  row  forty  to  sixty 
miles  a  day  without  fatigue.  He  can  travel  miles  with  a 
very  heavy  burden  on  his  back.  He  can  show  a  surpris- 
ing energy  and  muscular  endurance  in  his  native  dance 
and  can  accomplish  a  great  deal  of  work  in  the  fields.  A 
poor  laborer  for  a  wage,  he  is  an  excellent  worker  when 
getting  ready  for  a  celebration.  Isolation  from  contact 
with  the  other  races,  government  protection  from  com- 
mercial exploitation,  an  abundance  of  good  food  carefully 
prepared  and  well  cooked,  a  good  water  supply,  an  agri- 
cultural life,  well-built  houses,  an  equable  warm  climate, 
cleanly  personal  habits,  and  a  very  normal  type  of  sexual 
life  are  conditions  all  of  which  combine  to  make  the 
Samoan  a  healthy  animaL  Were  it  not  for  the  presence 
of  a  few  parasitic  and  infectious  diseases  which  atfect 
large  numbers  of  the  population — one  individul  often  har- 
boring two  or  more  infections — sickness  would  be  almost 
unknown  among  them. 


186  TllOPICAL    SURGERY    AND    DISEASES 

GrUAM. — Odell,-  service  during  1909-1911.  The  natives 
are  Chamorros ;  j)opulation  ahont  12,000;  American  sail- 
ors, marines,  civil  emploj^ees  and  civilians  who  are  per- 
manent residents  of  the  island,  number  about  250;  Jap- 
anese, Spaniards,  and  others  number  about  100.  The 
American  x)opulation  as  to  their  physical  condition,  food 
and  habits  do  not  differ  to  any  degree  from  what  they 
would  be  in  the  United  States.  The  native  xjopulation 
had  been  so  changed  by  the  admixture  of  Filipino  blood 
during  Spanish  possession  of  the  Island  that  there  is 
great  doubt  if  there  now  is  a  pure  blood  Chamorro  left. 
Today  the  Chamorro  resembles  the  Filipino.  Rice  is  the 
main  food  of  the  native,  though  yams,  corn,  cocoanut, 
the  few  fruits  native  to  the  island,  and  the  nuts  from  cer- 
tain varieties  of  palm  are. used  to  a  considerable  extent. 
Fish  forms  a  smaller  part  of  the  diet  than  is  conunon  in 
most  tropic  islands,  owing  to  the  abseiice  of  shoals 
where  fish  can  be  taken,  and  beef  is  used  to  a  greater  ex- 
tent. 

Agra,  Iis^^dia." — Hindus  of  various  castes,  Mohammed- 
ans, and  Christians  have  been  admitted  in  the  hospital 
for  surgical  and  medical  treatment.  The  general  physi- 
cal condition  of  about  30  per  cent  is  fair,  but  that  of 
about  70  per  cent  is  indifferent.  The  majority  enter  in 
advanced  stages  of  disease.  A  large  number  of  Hindus 
are  vegetarians,  but  those  who  eat  meat  generally  take 
it  as  an  accessory  diet.  Bread  and  rice  form  their  chief 
foods.  Among  Mohammedans,  although  all  of  them  are 
meat  eaters,  the  meat  dish  forms  only  an  accessory  part 
of  the  diet,  their  chief  foods  also  being  bread  and  rice. 
Indians  use  a  large  amount  of  chilies  in  their  food.  They 
make  their  food  palatalile  l)y  the  addition  of  condiments, 
cloves,  cardamoms,  cinnamon,  caraway,  asafetida,  and  a 
powder  made  from  dried  mangoes.  The  better  class  In- 
dians use  a  lot  of  ghee  (liquid  butter)  and  milk  witli 
their  food.     The  majority  of  people,  especially  among 


AXSWEItS    T<>    (a'KSTIOXXAlltH  J8< 

the  poor,  take  only  one  princiijal  meal  daily  about  2  p.m. 
For  breakfast  tliey  take  a  small  quantity  of  pai-eliecl 
grain,  etc.  The  better  class  Indians  take  two  principal 
meals  daily  with  light  refreshment  in  the  morning  and 
afternoon.  Hindus  and  Mohammedans  are  practically 
all  total  abstainers  as  regards  alcohol,  though  some  of 
the  lowest  castes  drink  native  distilled  liquors  in  excess. 
Zameoanga,  p.  1.'"^ — Tlie  general  physical  condition  of 
Moros  is  apparently  good,  but  when  taken  sick  they  show 
slight  resistance.  The  Filipino  is  more  resistant  to  dis- 
ease, lives  better,  and  is,  as  a  rule,  fairly  well  off.  The 
principal  food  of  all  classes  is  rice  and  fish.  The  Moros 
eat  less  meat  than  do  the  Filipinos.  The  habits  of  the 
Moros  are  indescribal)ly  unsanitary.  They  bathe  occa- 
sionally and  have  no  household  hygiene.  Moros  always 
defecate  in  water  and  wash  after  .defecation,  using  the 
left  hand.  The  left  hand  is  thus  dishonored  and  is  not 
used  in  the  ''chow"  pot.  As  this  is  their  only  hygienic 
practice  it  does  little  good,  except  that  the  ground 
around  Moro  dwellings  is  not  full  of  hookworm,  but  the 
streams  are  polluted  with  typhoid,  cholera,  and  dys- 
entery. 

South  Africa. ^'^ — Turner-^  dealt  ])rincipally  with  the 
natives  from  Portuguese  East  Africa,  that  is,  boys  re- 
cruited for  the  mines  between  Delagoa  Bay  and  Mozam- 
l)ique.  These  natives  may  be  roughly  divided  into  those 
coming  from  south  of  latitude  22°  S.,  and  those  from 
north  of  that  latitude.  The  former  are  looked  upon  as 
nontropicals,  the  later  as  tropicals.  The  nontropicals 
consist  of  four  or  five  well  marked  tribes ;  viz.,  Hangaan, 
Mtyopi,  Inlambane  boys,  and  Delagoa  Bay  natives, 
principally  Tongas.  The  tropical  natives  are  a  very 
mixed  lot,  as  may  be  judged  from  tlic  wide  area  over 
Avhich  tlicy  are  recruited;  they  vai'y  from  Swahili  and 
.good  class  central  African  Aiigoui  and  Jao  natives  to 
some  verv  low  class  trilx's  on  the  Zamliezi. 


188  TROPICAL    SURGERY    AND    DISEASES 

West  Afeica.® — Hollenbeck®  finds  the  natives  of  good 
pliysique  but  wholly  insanitary ;  they  live  on  corn  meal, 
beans,  meat,  fruit  and  vegetables. 

Colombo,  Ceylox.' — Two  thirds  of  the  population  are 
Singhalese,  2,230,897.  The  rest  is  composed  of  Tamils, 
951,740;  Moors,  228,034;  Burghers,  23,482;  Malays,  11,- 
902;  Europeans,  6,300;  other  races  including  Afghans, 
Kaffirs,  Chinese,  Japanese,  etc.,  9,718;  Veddahs,  3,971. 
Of  these  the  Singhalese  are  of  Aryan  stock,  but  mixed 
with  Dravidian  stock.  The  Tamils  are  Dra^ddians.  The 
Moors  are  mostly  Dravidians  who  have  been  converted 
to  Mohammedanism,  Avhile  a  few  claim  an  Arabian  de- 
scent. The  Malays  are  Mongolian,  the  Burghers  are 
descendants  of  the  Portuguese  and  Dutch  settlers.  A 
good  number  of  them,  however,  are  of  mixed  stock.  The 
merchant,  trading  and  professional  classes  have  a  ten- 
dency to  obesity  and  a  good  proportion  develop  diabetes. 
The  laboring  classes  are  generally  thin,  but  well  de- 
veloped, strong  and  cajDable  of  substantial  work.  The 
Singhalese  as  a  rule  are  inclined  to  be  lazy  and  will  not 
work  unless  necessity  compels  them.  The  Tamils  are 
more  active  and  industrious.  The  Moors  are  generally 
traders.  The  Burghers  belong  mostly  to  the  profes- 
sional or  clerical  ser^-ices,  while  a  good  many  of  them  are 
mechanics.  The  indigenous  population  subsists  chiefly 
on  rice  and  curr3\  The  large  majority  of  the  Singhalese 
and  Tamils  are  vegetarians,  while  those  who  are  in  large 
toA^^ls  take  a  mixed  diet.  Alcohol  is  consumed  largely  by 
residents  of  to^^iis.  The  majority  of  the  population 
practices  total  abstinence.  Opium  is  very  little  used, 
and  only  by  persons  Avho  are  subject  to  some  chronic  mal- 
ady.   Tobacco  smoking  is  very  common. 

Shoka,  Formosa.® — Poj)ulation,  3,000,000  Chinese;  70,- 
000  Japanese;  100,000  aborigines.  The  Chinese  are 
mostly  rice  farmers,  living  among  the  rice  swamps ;  some 
of  the  civilized  aborigines  come  as  patients  but  none  of 


AXSWERS    TO    QL'E.STIOXXAIRE  189 

the  wild  savages.  Many  are  of  Malay  stock.  The  food 
of  the  Chinese  and  civilized  aborigines  is  rice  with  veg- 
etables, fish  and  sometimes,  though  rarely,  pork. 

KoREA.^ — Mills  and  sixteen  colleagues.  Population, 
Koreans,  12,000,000;  Japanese,  200,000;  Chinese,  25,000; 
Foreigners  (Americans,  British,  etc.,)  400.  Classes  of 
patients  :  Patients  treated  by  us  are  almost  entirely  Ko- 
reans, the  Japanese  being  treated  by  their  own  physi- 
cians and  druggists.  Hospital  and  dispensary  patients 
are  largely  from  the  middle  and  loAver  classes,  although 
the  aristocrats  are  frequently  reached;  women  come 
quite  freely  to  the  male  physicians  for  treatment  in  most 
stations,  especially  in  the  Xorth.  Koreans  physically 
are  fairly  well  developed.  A  recent  army  examination 
covering  some  thousands  of  men  gave  a  range  in  height 
of  from  4  feet  11  inches  to  6  feet  3  inches.  The  weight 
would  probably  be  less  than  exx)ected  from  the  height. 
The  ordinary  coolie  often  is  fairly  muscular  and  larger 
than  the  Japanese,  but  averages  less  than  the  Manchu- 
rian  Chinese.  The  middle  classes,  chiefly  merchants  and 
shop  keei)ers,  are  not  so  well  developed  and  their  more 
sedentary  habits  have  not  made  them  fleshy.  The  ' '  Yang 
])ans,"  or  aristocrats,  are  so  averse  to  manual  labor  and 
indulge  their  appeties  to  such  an  extent  that  weak  bodies, 
indigestion,  sexual  neurasthenia  and  impotence  at  an 
early  age  are  very  common.  A  fat  Korean  is  a  rarity 
although  the  women  are  inclined  to  be  a  little  more 
plump. 

General  dietary:  Rice  and  millet  are  the  staples; 
"kim  chee,"  a  kind  of  sauerkraut  composed  of  native 
cabbage  and  turnips  with  salt,  red  pepper  and  other  in- 
gredients "to  taste"  is  also  widely  eaten.  AVheat  and 
buckwheat  are  chiefly  used  in  ''cook  soo"  a  boiled  vermi- 
celli, Avhile  oats  and  barley  are  less  important.  Corn  is 
chiefly  eaten  off  the  cob  when  the  "milk  stage"  is  nearly 
past,  and  when  matured  is  used  only  for  animals.    Beans 


190  TROPICAL    SURGERY    AXD    DISEASES 

are  used  in  a  variety  of  ways  and  to  a  considerable  ex- 
tent. Broomcorn  is  chiefly  g'ro^\T[i  for  the  seed  from 
Avhich  Avhiskey  is  made.  Dried  fish  in  the  interior  and 
fresh  ones  near  the  coast  are  much  nsed,  Avhile  chickens 
and  eggs  are  eaten  by  the  better  classes.  Pork  and  dog 
meat  enter  into  the  menus  of  feasts  to  a  considerable 
extent,  and  beef,  often  from  worn-ont  or  diseased  ani- 
mals is  eaten.  AVhile  the  dietary  is  perhaps  sufficient 
for  the  native  under  his  normal  conditions,  it  does  not 
seem  sufficient  to  meet  the  demands  of  a  more  intense 
life.  In  the  game  districts  the  Koreans  eat  a  great  deal 
of  fresh  good  beef,  hare,  deer,  pheasant,  duck,  geese  and 
at  times  horse,  donkey,  and  even  leopard.  Koreans  will 
not  eat  XDigeon  because  of  an  old  superstition  that  there 
can  be  but  one  boy  and  girl  born  in  the  family  if  they 
do  so. 

General  Resistance  of  Patients  to  Surreal  Measures — 

Shock — Anesthetic  Used — Infection  of  Operation 

Wounds — Percentage  of  Aseptic  Results 

in  Clean  Cases 

BuEMA." — General  resistance  to  surgical  measures  is 
good  in  natives  of  a  hot  climate,  but  not  so  good  as  in  Eu- 
roi)eans.  Chloroform  is  used,  AVound  infection  seldom 
occurs  and  is  probably  in  one  respect  less  likely  to  oc- 
cur from  hands  in  this  damp,  warm  climate  than  in  a 
cool  European  climate,  because  constant  perspiration 
makes  it  easier  for  the  operator  to  cleanse  his  hands. 

Agea,  IjStdia." — The  general  resistance  of  the  hospital 
patients  is  good  and,  being  mostly  vegetarians,  their 
wounds  heal  well.  Shock  in  ordinary  operations  is  sel- 
dom observed,  but  they  do  not  stand  the  more  severe 
operations,  particularly  on  the  abdominal  cavity,  so  well 
as  "Western  races.  Chloroform  is  almost  always  used. 
Infection  of  operation  wounds  is  rarely  noticed,  and  the 


AXSWKItS    TO    (il"i;s'l'l()X.\Ali;R  11)1 

])('!•('(' 1 1  ta,i;T'  of  aseptic  results  in  clean  cases  is  prac- 
tically 99  per  cent. 

Zamboaxga,  p.  I.^"' — Moros  resist  surgical  wounds  bet- 
ter than  Filipinos,  Init  they  do  not  resist  medical  diseases 
so  well.  The  Moro  is  more  of  a  fatalist  than  the  Filipino 
and,  AA'hen  sick,  gives  up  and  dies,  Moros  Avith  simple 
diseases  will  refuse  to  eat  so  as  to  hurry  up  the  end  that 
they  are  sure  is  near.  The  small  meat  ration  of  the 
Moro  also  nndouhtedly  affects  his  resistance  unfavora- 
bly. Xatives  are  almost  immmie  to  pus  infection.  Have 
never  seen  shock  in  a  native  during,  operation.  Shock 
has  been  seen  after  severe  injuries  and  in  these  cases  the 
reaction  was  satisfactory  even  though  death  afterwards 
resulted.  Anesthetic  ^^I'^f^i'i'^cl  is  ether,  drop  method. 
Aseptic  results  are  the  rule  in  clean  cases. 

Hoi^GKOXG." — Europeans  unaffected  by  the  subtrop- 
ical climate.  Chinese  are  ver^'  susceptible  to  sliock  but 
stand  operations  under  local  anesthesia  which  in  the  for- 
mer would  necessitate  a  general  anesthetic ;  sensilnlity  in 
the  Chinese  seems  not  so  highly  developed  as  in  AYest- 
erners.     Chloroform  is  the  general  anesthetic. 

SoocHOw,^  PixG  Yix,^-  AND  AVexchow,^^  Chixa. — The 
general  resistance  of  the  people  to  surgical  treatment  is 
the  same  as  in  American  hospitals.  Percentage  of  deaths 
following  operation  is  high,  but  this  is  due  to  coming  in  a 
very  poor  condition  to  withstand  surgical  interference. 
Shock  usually  is  slight.  Chloroform  is  used.  Infection  is 
I'are  in  a  clean  case;  iodine  solution  is  used  to  ])re]")are 
skin. 

vSouTH^*  AXD  AVest'"'  Africa. — General  resistance  of  na- 
tive patients  to  surgical  measui-e  is  good;  good  asepsis 
in  clean  cases. 

Colombo,  Ceylox.' — As  a  rule  patients  stand  opera- 
tive measures  well.  The  laboring  classes  make  better 
recoveries  than  others ;  shock  is  not  marked  except  in 
very  prolonged  operations  or  in  women  and  cliildren  of 


192  TROPICAL    SURGERY    AXD    DISEASES 

a  neurotic  type.  Cliloroforni  is  universally  used.  In 
Aveakly  individuals  A.C.E.  mixture  is  used.  Strepto- 
coccic infection  is  very  uncommon,  and  staphylococcic  in- 
fection sometimes  occurs;  ninety  per  cent  of  tlie  clean 
cases  run  an  ase]3tic  course. 

Shoka,  Formosa.^ — Stand  operations  Avell.  Do  not 
readily  suffer  from  shock:  chloroform  as  general  anes- 
thetic, and  cocaine  as  local:  do  not  use  drop  method. 
Operative  wounds  are  rarely  infected. 

Samoa. ^ — Surgical  patients  do  very  well.  Prolonged 
anesthesia  and  severe  operations  seem  to  be  as  well  re- 
covered from  as  in  the  white  races  in  temperate  climate ; 
shock  is  less  to  be  feared  than  in  the  white  races.  Chlo- 
roform has  been  used  almost  exclusively  for  the  past 
five  years  in  major  cases  and  ethyl  chloride  general  anes- 
thesia in  minor  ones  without  a  single  untoward  effect  in 
the  last  500  cases  of  general  anesthesia.  Wound  infec- 
tions in  clean  operations,  except  of  the  scrotum,  are  as 
rare  as  in  temperate  climates. 

Guam.- — The  Japanese  bear  surgical  operations  well. 
The  Chamorros'  resistance  is  somewhat  less.  Shock  is 
greater  than  with  our  j)eoiDle,  and  seems  abnormally  so 
in  operations  upon  the  intestines  and  pelvic  organs. 
This  was  attributed  to  the  anemia  from  hookworm  in- 
fection wliich  is  almost  universally  present  in  some  de- 
gree. A  rather  poor  diet  was  no  doubt  also  a  contribut- 
ing factor.  Ether  by  the  dro]D  method  was  the  anes- 
thetic employed,  but  chloroform  had  been  formerly  used 
to  a  considerable  extent;  no  deaths  had  occurred  from 
its  use.  No  infection  of  operative  wounds  occurred; 
cases  doing  as  well  in  this  respect  as  those  operated  in 
the  United  States.  The  patients  were  very  tractable 
when  they  were  in  the  hospital,  being  better  in  this  mat- 
ter than  our  ovvm  people. 

KoREA.^ — General  resistance  very  good.  Shock  seldom 
seen.    Anesthetic  chiefly  chloroform,  although  ether  has 


ANSWERS    TO    QX'ESTIONNAIRE  ll)6 

been  more  used  in  Seoul.     Operative  Avonnds,  generally 
clean.    Iodine  nmch  nsed  in  preparation. 

The  Most  Common  and  Frequent  Surgical  Diseases 

Ceylon." — Inguinal  hernia  ;  hydrocele ;  appendicitis ; 
hemorrhoids. 

Formosa.® — Malaria  and  its  sequelae,  enlarged  spleen, 
anemia;  round  worms,  ankylostomiasis,  dysentery. 

Korea." — The  most  common  and  frequent  diseases  are : 
tuberculosis,  syphilis,  malaria,  chronic  gastritis,  otitis 
media,  indigestion,  bronchitis,  and  diarrhea. 

Climate:  Influence  on  Foreigners  and  on  Natives 

BuRMA.^'' — Enervating  on  both  foreigners  and  on  na- 
tives. 

Agra,^  India. — The  climate  is  very  hot  and  dr}'-  in  the 
summer,  and  cold  and  dry  in  the  winter,  and  it  is  gen- 
erally a  healthy  one.  Natives  stand  the  climate  well  and 
are  usually  well  nourished  and  healthy;  foreigners  also, 
provided  they  get  their  periods  of  change. 

Hongkong. ^^ — Foreigners  age  more  rapidly,  especially 
those  addicted  to  alcohol  and  sexual  excess;  presbyopia 
commences  at  least  three  3^ears  earlier,  ciliary  exhaus- 
tion and  cramp  are  commoner  than  in  temperate  zones 
among  young  hypermetropics. 

AVenchow^^  and  Ping  Yin,^-  China. — Climate  has  an 
enervating  effect  on  all  foreigners  and  to  a  less  extent  on 
the  Chinese. 

Ceylon.^— Foreigners  generally  lose  the  power  of  sus- 
tained effort  and  are  easily  tired  after  a  i)eriod  of  three 
years.  The  skin  becomes  bronzed.  Some  of  those  Eu- 
ropeans who  have  adopted  the  Cejdonese  diet  of  rice  and 
curry,  abstained  from  much  meat  eating  and  either  ab- 
stained from  alcohol  or  used  it  moderately,  have  acclima- 
tized themselves,  and  lived  to  good  old  ages,  without 
visiting  Europe. 


194  TROPICAL    SURGERY   AlifD   DISEASES 

Formosa." — Climate  very  enervating  to  Europeans,  in 
summer  especially;  moist  hot  climate.  Natives  are  ac- 
customed to  it  and  stand  it  better. 

Samoa.^ — Climate  alone  seems  to  exert  but  little  effect 
upon  the  foreigner.  The  continued  even  warm  tempera- 
ture will,  after  a  year  or  so,  cause  him  to  feel  slight 
changes  in  temperature,  which  in  a  more  temperate  zone 
he  would  not  notice.  For  the  native  the  climate  seems 
to  be  practically  perfect. 

Guam,- — Climate,  the  best  in  the  Tropics  in  that  lati- 
tude. Daily  temperature  at  noon  not  high,  evenings  al- 
ways cool  so  that  light  cover  is  agreeable.  The  Euro- 
pean who  stays  tAvo  or  three  years  in  this  part  of  the 
world  and  who  protects  himself  against  the  fly  and  the 
mosquito  to  a  reasonable  degree,  can  work,  either  men- 
tally or  physically,  at  the  same  pressure  and  during  the 
same  hours  as  in  a  temperate  zone.  A  longer  stay,  five 
years  or  more,  will  subject  him  to  a  real  risk  of  con- 
tracting filariasis.  The  native  population  seems  to  suf- 
fer more  from  epidemic  asthma  during  the  seasons  of 
greatest  rain,  July  to  October. 

KoREA.^ — Climate  generally  bracing  all  over  Korea.  In 
the  winter  a  little  snoAv  and  ice  in  the  South  with  cold 
winds  and  gradual  changes  of  temperature.  In  the 
North  the  Avinds  are  not  severe,  the  ice  on  the  river 
reaching  a  thickness  of  two  and  one-half  feet.  Spring 
and  fall  are  delightful  everywhere.  The  rainy  season 
is  very  debilitating  in  the  southern  and  central  portions. 
Electrical  demonstrations  in  connection  with  storms  are 
infrequent  and  accidents  of  any  kind  from  lightning  are 
rare.  Effects  upon  foreigners  :  Menstrual  irregularities 
or  suppression  common;  nerve  tire;  sleepiness  during 
first  year  common;  debility  and  headaches  in  the  rainy 
season.  As  to  the  latter  condition  no  such  marked  cases 
are  seen  as  those  commonly  denoted  "Japan  head"  so 
frequent  among  women  in  Japan.    Diarrhea  during  first 


ANSWERS    TO    QT^ESTIONXAIRE  195 

summer;  increased  nervousness ;  some  danger  of  heat  ex- 
haustion; rainy  season  very  depressing,  the  rest  of  the 
year  exhilarating.  Hard  Avork  in  this  beautiful  and  brac- 
ing climate  seldom  hurts  any  one.  Etf  ect  upon  natives : 
Koreans  in  the  North  are  observed  to  be  taller  and  of  a 
sturdier,  more  reliable  character  than  those  in  the  South. 
The  colder  the  climate,  the  more  the  people  crowd  to- 
gether in  small  houses  with  all  the  evils  arising  from 
such  conditions.  Exposure  to  the  cold  and  rain  with  in- 
sufficient clothing  leaves  its  impression.  It  is  said  that 
tuberculosis  is  more  prevalent  in  the  South  where  the 
climate  is  more  mild  and  exposure  not  so  great. 

Europeans:    Habits,  Exercise,  Periods  of  Service,  Preva- 
lence Among  Them  of  Diseases  of  Hot  Regions 

Burma." — Climate,  temperate  arid  regular;  active  ex- 
ercise the  rule.  Leave  of  one  year  should  be  given  every 
three  years.  After  a  stay  of  three  years  in  the  climate 
of  Burma,  resistance  to  tropical  diseases  is  much  lower 
and  their  prevalence  becomes  marked. 

Manila.^^ — Habits  and  exercise  should  be  adjusted  for 
the  good  of  each  individual  and  no  hard  and  fast  rules 
can  be  laid  do-v\m.  The  enlisted  men  and  most  line  offi- 
cers take  considerable  exercise  and  benefit  thereby. 
American  women  almost  universally  take  practically  no 
exercise  in  the  Philippines  and  this,  combined  with  a  too 
strenuous  social  life  for  many  who  live  in  Manila,  is,  we 
believe,  the  cause  of  a  large  number  of  cases  of  tropical 
neurasthenia.  The  main  habit  to  be  avoided  is  an  undue 
use  of  alcohol,  the  effects  of  which  are  the  same  here  as 
elsewhere.  For  various  reasons  there  is  a  tendency  to 
use  more  alcohol  here  than  at  home.  There  is  also  a  ten- 
dency to  avoid  taking  a  sufficient  amount  of  exercise  be- 
cause of  the  heat.  The  prevalence  of  ' '  tropical  diseases ' ' 
depends  upon  the  habits  of  life  and  hygienic  surround- 
ings.   With  proper  care  they  may  all  be  avoided  in  most 


196  TROPICAL    SUllGERY    AXD    DISEASES 

instances.  The  tour  of  duty  at  present  in  force  for  the 
arni}^  is  two  years.  This  ^ye  believe  to  be  a  suitable  one 
when  all  factors  are  considered. 

Agra,  Ixdia.^ — Euroi3eans  live  very  abstemious  lives 
nowadays,  take  little  or  no  alcohol  in  the  hot  weather, 
and  live  sparingly.  All  the  year  round  exercise  is  taken 
daily,  and  Europeans  find  it  necessary  to  have  the  re- 
laxation, especially  those  whose  work  is  continuous  and 
hard.  Exercise  takes  the  form  of  riding,  e.  g.,  polo  all 
the  year  round,  pig  sticking  in  the  hot  weather,  tennis, 
racquets,  and  golf  all  the  year  round,  cricket  in  the  cold 
weather,  football  and  hockey  also  the  year  round.  The 
usual  full  period  of  service  for  pension  is  thirty  years, 
but  pensions  can  be  taken  after  twenty  and  twenty-five 
years.  Government  servants  are  forcibly  retired  at  55 
unless  above  a  certain  rank  which  only  a  small  percent- 
age attain.  The  period  of  leave  of  absence  to  England 
is  usually  one  year  in  five,  but  the  average  amount  of 
leave  taken  is  not  so  much  as  this;  usually  about  eight 
months  leave  home  in  five  ^^ears.  At  the  x>resent  time 
with  the  healthier  conditions  of  life  in  India  *' tropical" 
diseases  are  very  much  less  coimnon  than  they  used  to 
be.  Cholera  and  liver  abscesses  are  rare  among  Euro- 
peans ;  dysentery  is  seen,  but  is  chiefly  of  a  mild  type  and 
malaria  is  far  less  common  than  it  used  to  be. 

HoxGKOX-G,  Chixa.^^ — 111  at  least  50  per  cent  there  is 
tendency  to  drink  more  alcohol  than  is  good  for  the  hu- 
man body  mthout  going  so  far  as  to  term  this  alcoholic 
excess.  Exercise:  Every  variety  of  game  is  indulged 
in.  As  a  rule  five  years  of  service  is  required  by  the 
majority  of  firms  and  then  one  year's  leave. 

SoocHOw,  Chixa." — Out  of  doors  a  great  deal.  About 
a  seven-year  service  and  one-year  furlough.  Malaria  is 
very  common,  tertian  and  subtertiaii.  The  usual  intes- 
tinal parasites  are  very  common. 

Ceylox." — Europeans,  as  a  rule,  go  in  a  good  deal  for 


ANSWEIJS    TO    QUKSTIONXAIRE  1*J7 

horse  riding,  cycling,  golf,  tennis  and  cricket,  hut  nn- 
fortmiately  a  good  nnmber  of  them  take  whiskey  in  ex- 
cess, particularly  after  exercise.  Generally  they  go  on 
leave  for  a  period  of  six  months  to  a  year  after  every 
five  years.  Enteric  fever,  dysentery,  diarrhea,  and 
sprue  are  some  of  the  common  tropical  diseases  to  which 
they  are  subject. 

FoEMOSA.® — Europeans  vary  much  in  regard  to  exer- 
cise and  habits.  The  tendency  is  to  live  too  well  and 
take  too  little  exercise.  Missionaries  serve  from  five  to 
seven  years  and  then  take  a  furlough  for  a  3"ear  or  more. 
Europeans  suffer  from  malaria  and  dysentery,  not  so 
much  from  malaria  now  that  their  houses  are  mosquito 
j)roofed. 

Guam.- — Europeans  exercise  less,  and  consume  more 
alcoholic  beverage  than  they  would' at  home.  The  period 
of  military  service  is  about  two  years,  and  during  that 
time  the  enlisted  personnel  and  officers  have  one  or  two 
trij)s  to  Japan  or  China  for  change.  Civil  employees 
and  residents  do  not  go  away  as  a  rule.  Some  of  the 
permanent  residents  have  been  there  for  years  mthout 
any  bad  effects.  Dengue,  furunculosis,  dysentery,  and 
tinea  are  seen.  ^Vlien  an  epidemic  occurs,  practically  all 
of  the  people  who  have  not  had  dengue  have  the  disease. 
Tinea  is  not  so  prevalent  as  it  Avas  in  the  foreign  popu- 
lation in  the  Philippines  ten  years  ago,  but  is  frecpently 
seen.  Furunculosis  is  fairly  connnon.  Dysentery  is  not 
very  common  owing  to  the  care  exercised  in  diet  and  the 
general  use  of  distilled  or  boiled  water.  The  American 
population  is  more  free  from  the  ailments  common 
among  the  natives  because  of  the  care  taken  with  diet 
and  a  better  hygienic  life.  Xo  case  of  epidemic  asthma 
(guha)  was  seen  in  the  American  population. 

KoKEA.^ — Effects  on  foreigners:  Menstrual  irregu- 
larities or  suppression:  sleepiness  during  the  first  year. 
Foreigners  are  chiefly  Americans.'    Habits  not  specially 


198  TROPICAL    SUEGERY   AND    DISEASES 

different  from  at  home.  Furlough  periods  for  mission- 
aries are  every  six  to  eight  years.  Troj)ical  diseases 
among  foreigners  are  found  only  in  the  South.  Sprue: 
several  cases ;  diagnosis  complicated  by  a  similar  symp- 
tom-complex in  nursing  mothers  that  clears  up  on  wean- 
ing the  child.  Dysentery:  a  number  of  cases,  folloAved 
by  liver  abscess  after  a  few.  Malaria :  very  common  in 
former  times,  less  so  now,  but  still  fairly  common  in 
more  southern  parts.  Relapsing  fever:  several  cases, 
especially  among  physicians.  Typhus  fever:  no  cases 
for  several  years. 

Wounds:  Infections,  Pathogenic  Causes,  by  Streptococcus, 

by  Staphylococcus,  by  Tetanus,  Etc.,  Native 

Treatment  of  Wounds 

Burma." — AVound  infections  are  not  marked.  Chief 
infection  by  staphylococcus.  That  by  streptococcus 
rare.  Tetanus  practically  nil,  since  routine  use  of  an- 
titetanic  serum  in  all  dirty  wounds ;  but  in  dirty  wounds 
treated  in  native  houses  this  infection  is  common,  much 
more  so  than  under  somewhat  similar  surroundings  in 
Europe. 

Agra,  India." — Infections  of  wounds  by  streptococcus, 
staphylococcus  or  tetanus  are  frequently  seen  in  the  out- 
patient room;  especially  in  compound  fractures.  These 
cases  are  dressed  Avith  mud,  cow  dung  or  any  filthy  rag 
and  after  some  days  brought  to  hospital.  It  is  always 
necessary  in  large  Indian  hospitals  to  have  separate  sep- 
tic wards  for  such  cases  and  amputation  of  limbs  is  very 
frequent. 

AVenchow^^  and  Ping  Yin,^-  China. — Wound  infections 
by  tetanus  and  other  pyogenic  bacteria  are  common. 

Ceylon.^ — Knife  wounds  are  fairly  common.  Blows 
with  clubs  and  fists  are  few  in  proportion.  Staphylococ- 
cic infections  are  more  common  than  streptococcic  in- 
fections.    Tetanus  occurs  in  association  with  lacerated 


ANSWERS    TO    QUESTIONNAIRE  199 

wounds,  compound  fractures,  and  sometimes  in  cases  of 
small  wounds  caused  by  the  mid-rib  of  a  cocoanut  leaf. 
Formosa.^ — ^Wound  infections  by  both  staphylococcus 
and  streptococcus  are  verj^  common.  Tetanus  is  not  un- 
common.    Tobacco  is  a  favorite  ap]3lication  to  wounds. 

Native  Treatment  of  Wounds  and  Diseases 

Burma." — Native  treatment  of  wounds  and  diseases 
crude;  largely  by  charms,  actual  cautery,  and  leaves  of 
sacred  trees. 

Ping  Yin,^-  China. — Native  treatment  of  wounds  is  by 
application  of  flour,  ashes,  earth,  etc.  Boils,  abscesses 
and  all  swellings  and  painful  areas  are  treated  by  appli- 
cation of  adhesive  plaster.  Acupuncture  most  frecpent 
method  of  treatment.  Other  methods  of  treatment  are 
pinching,  bruising,  thumping  and  the  cautery. 

Ceylon.® — There  are  three  systems  of  native  treat- 
ment; viz.,  the  Singhalese,  the  Tamil,  and  the  Moham- 
medan. Some  of  these  native  practitioners  have  ac- 
quired local  fame  in  the  treatment  of  particular  diseases. 
The  native  treatment  of  Avounds,  fractures,  and  sprains 
appears  to  have  given  satisfaction;  from  personal  e:j^ 
aminations  of  some  of  the  medical  cases  treated  by  na- 
tive practitioners,  I  must  admit  that  the  results  have 
been  satisfactory.  They  generally  use  medicinal  herbs 
and  pastes  made  of  leaves,  but  the  composition  of  their 
oils  and  pastes  is  kept  rigidly  secret  and  is  handed  doA\Ti 
from  father  to  son.  In  the  treatment  of  d^^sentery  both 
acute  and  chronic  they  are  very  successful.  Hysterical 
disorders  are  also  successfully  treated  by  them  and  there 
are  a  few  who  have  a  reputation  for  the  cure  of  snake 
bite. 

Samoa.^ — Wound  infection  is  the  rule  unless  the  wounds 
are  cared  for  surgically;  staphylococcus  aureus  being 
the  most  common ;  streptococcus  rare.  Tetanus  has  been 
observed  but  is  verv  rare.     The  natives  treat  a  wound 


200  TROPICAL  SUEGEEY  AXD  DISEASES 

hy  neglect  until  infection  occurs  and  then  by  bathing  it 
in  the  sea.  At  a  later  stage  Avhen  healing  has  begun,  the 
wonnd  is  sealed  ^^ith  leaves  to  keejD  out  flies  and  dirt. 
The  native  treatment  of  other  diseases  is  largely  contuied 
to  M'hat  they  call  "Innii  lumi, "  a  well-developed  form  of 
general  massage,  at  times  gently  used  so  as  to  give  relief 
to  the  patient,  at  other  times  administered  with  sufficient 
force  to  do  harm.  Xot  infrequently  abortions  are 
brouglit   on  in  this  way. 

Gua:\i.- — "Wound  infections  were  fairly  frequent  among 
the  natives  o^\ing  to  the  filthy  dressings  applied  at  the 
time  of  injury  and  the  time  necessary  to  convey  the  pa- 
tient to  the  doctor,  as  the  injuries  generally  took  place 
on  the  ranches  some  miles  from  Agaiia  where  the  hos- 
pital is  located.  It  was  surprising  how  frequently  clean 
results  were  obtained  in  serious  wounds,  gores  from  bulls 
and  the  like,  that  were  fairly  common  and  where  the 
wound  had  every  opportunity  for  infection.  Streptococ- 
cus infections  were  not  conunon ;  stai3hylococcus  was  the 
common  infecting  agent  and  pyocyaneus  infection  Avas 
more  frecpient  as  an  accomi^anying  infection  than  in  any 
ether  place  that  I  have  observed.  Tetanus  was  fairly 
frequent  in  punctured  wounds  and  tetanus  neonatorum 
was  conunon  in  Agaiia  until  the  first  of  1912  when  the 
old  system  of  midwives  was  abolished.  Natives  have  no 
treatment  for  womids  different  from  that  among  our  oavu 
people. 

Korea. ^ — Native  treatment  of  Avounds  and  diseases: 
Cover  with  hard  dressings,  hot  dressing,  chicken  split 
open,  soot,  pitch  plaster,  dog  manure,  occlusive  dress- 
ings. oil-i3aper,  mud,  cow  manure  to  cervical  adenitis  and 
cuts,  fresh  dog  skin,  tobacco  leaves,  lime,  salt,  boiling 
oil,  bird  dung  for  eczema;  some  use  starch  j)aste  or  cob- 
Avebs  in  early  stages  and  later,  leaf  poultices  or  black 
Avax;  kerosene  has  been  used  lately.  Urine  serves  as  an 
eA'e  Avash  and  for  Avounds  on  horses ;  Avounds  A^uth  hem- 


Aj^swers  to  questionnaire  201 

orrhage  are  bandaged  with  leaves  or  sometimes  a  plaster 
of  pitch ;  a  constriction  bandage  is  used  for  snake  bite ; 
contusions  are  treated  with  mud  or  occasionally  Avith 
clnng;  splints  for  fractures  are  bound  with  excessive 
tightness.  Cauterization  of  sacral  region  is  done  for 
malaria,  of  the  anterior  fontanelle  for  comoilsions  in 
children,  of  the  protruding  parts  for  uterine  iirolapse; 
inoxa  is  also  used;  acupuncture  is  done  for  rheumatism, 
neuralgia,  joint  affections,  and  all  sorts  of  pain.  Mer- 
cury vapor  inhalations  are  used  for  syphilis,  often  re- 
sulting in  salivation.  Hot  sweat  baths,  counterirrita- 
tion  and  blood-letting,  (short  needles  repeatedly  applied) 
and  suli3hur  baths  for  scabies  are  some  of  their  treat- 
ments. Among  the  variety  of  internal  medicines  are 
ginseng,  deer's  horns,  tigers'  bones  and  teeth,  urine  of 
a  baby,  dog  meat  soup,  and  one  case  is  reported  of  the 
menstrual  blood  of  a  virgin  being  prescribed  for  a  sick 
young  man.  Santonin  and  quinine  are  coining  into  com- 
mon use.  All  medicines  are  taken  in  great  quantities 
and  very  largely  diluted.  Many  cases  of  ordinary  sore 
throat,  tonsillitis  and  enlarged  tonsils  are  thought  to  be 
specific  and  great  harm  results  from  the  aiDplication  of 
the  yellow  oxide  of  mercury  locally  and  in  the  nose,  as 
well  as  the  inhalation  and  the  insufflation  of  other  com- 
pounds. 

The  iDractice  of  medicine  in  Korea  is  largely  borrowed 
from  China  although  a  great  manj^  of  the  medicinal 
plants  are  gathered  on  the  hills.  The  treatment  is  chiefly 
symptomatic  and  the  ''shot  gun"  prescription  is  found 
at  its  Avorst.  To  say  that  all  such  medication  is  inefficient 
or  harmful  Avould  be  carrying  the  matter  too  far.  Acute 
gastritis  and  the  malnutrition  of  infants  react  A^ery  un- 
f aA^orably  under  this  treatment  Avhile  ' '  indigestion ' '  does 
as  Avell  on  such  decoctions  as  on  any  other  line  of  treat- 
ment so  long  as  the  patient  himself  Avill  not  or  can  not 
remove  the  cause.    Acupuncture  A^itll  the  long  needle  has 


202  TROPICAL    SURGERY    AK^D    DISEASES 

resulted  very  disastrously  in  manj?^  bone  and  abdominal 
cases  and  the  absence  of  such  results  in  thousands  of 
other  cases  must  be  due  to  the  special  dispensation  of 
a  kindly  Providence  and  an  acquired  immunity  to  ordi- 
nary pus  infections. 

Dr.  Stryker  of  Pyeng  Yang*  adds  the  folloAmig:  after 
injury  from  a  fall,  the  Koreans  drink  dog's  dung  mixed 
in  water;  to  prevent  poisoning,  drink  their  o^^^l  urine; 
for  inguinal  adenitis,  apply  nicotine  from  pipe,  scratch 
with  dry  snake  tail,  apply  hot  rice  poultice;  iistula-in- 
ano,  apply  hot  iron;  sore  eyes,  apply  nicotine,  snakes' 
gall  or  small  piece  of  gold  to  eyelid ;  boils,  oral  suction, 
soot,  bear's  grease;  hemorrhages,  hot  candle  grease,  hot 
ashes,  dyes;  dysentery,  rice  powder  and  water,  acorns 
powdered  with  honey,  yelloAv  pine  tree  fioAvers  powdered 
and  mixed  with  honey  and  soot;  diarrhea,  dried  vermi- 
celli and  thick  A^ine,  red  bean  candy  boiled  in  Avine ;  indi- 
gestion, strong  salt  AA^ater,  bean  sauce;  during  rainy  sea- 
son, water  dripping  from  an  old  straw  roof;  bronchitis, 
vinegar,  raAv  pear  Avith  pepper  (cook  and  eat  hot),  honey 
and  pork;  dropsy,  fresh  bull  skin  and  lie  in  it  on  hot 
floor,  pig's  grease  applied  to  body;  tyi)hus  feA^er,  eat  bar- 
ley gruel,  Avhite  dog's  dung  soaked  in  Avater  and  used  as 
a  drink,  virgin's  menstrual  blood  soaked  in  Avater  and 
used  as  drink;  malaria,  make  x^atient  Avalk  during  chill 
or  face  sun  and  bleed  from  nose  Avitli  needle,  or  scare 
patient  Avhile  in  chill  by  means  of  snake,  etc. ;  tapcAvorms, 
eat  acorn  nuts  one  handful;  round  worms,  diink  boiled 
castor  oil;  stomatitis  in  children,  AA'hite  dog's  dung  poAV- 
dered  and  put  in  mouth,  also  hot  dog  grease ;  pulmonary 
tuberculosis,  drink  human  blood,  eat  raAv  placenta ;  gon- 
orrhea, vermicelli  Avater,  SAvalloAv  dung  mixed  in  Avater, 
hot  steam  locally ;  syphilis,  inhalations  of  poAvdered  mer- 
cury; tuberculous  glands  of  the  neck,  musk  poAATler;  ec- 
zema, man's  hair,  oil,  and  dust  from  a  high  shelf  mixed 
and  applied;  to  prcA^ent  abortion,  take  a  piece  of  Avood 


ANSWERS    TO    QUESTIONNAIRE  UUd 

from  handle  of  a  Avell  bucket,  burn  and  dissolve  ashes  in 
water  and  drink. 

The  Most  Common  and  Frequent  Diseases 

Burma/" — Tuberculosis. 

Agra,  India. ^ — The  disease  for  which  during  the  whole 
year  there  is  the  largest  hospital  attendance  is  malaria, 
otherwise  there  is  no  specially  prominent  disease. 

South  Africa.^* — The  most  common  disease  varies  ac- 
cording to  the  locality.  On  the  Transvaal  Gold  Mines 
pneumonia  causes  more  trouble  among  natives  than  any 
other  disease.  Cerebrospinal  meningitis  occasionally  oc- 
curs in  epidemic  form  among  natives.  Spirillum  fever, 
the  result  of  the  bite  of  Arnithodoran  Montata,  is  preva- 
lent in  places ;  malaria  is  universal  in  the  low  ground  and 
causes  invalidism  among  natives  during  childhood  and 
early  youth. 

HoNGKONG,^^  Wenchow,^^  China, — Europeaus :  gonor- 
rhea and  abdominal  complaints.  Chinese :  trachoma, 
syphilis,  tuberculosis,  intestinal  parasites,  malaria,  dys- 
entery. 

Ceylon.'^ — The  most  common  and  frequent  surgical 
diseases  are  inguinal  hernia,  hydrocele,  appendicitis, 
hemorrhoids. 

Formosa.® — Malaria  and  its  sequelae;  enlarged  spleen 
and  anemia,  round  worms,  ankylostomiasis,  dysentery. 

Samoa,^ — There  are  several  very  common  and  frequent 
diseases  which  are  given  below  Avith  a  rough,  but  accu- 
rate, estimate  of  their  frequency  in  the  population.  1. 
Nematode  infections :  ascariasis,  about  80  per  cent  of 
native  children ;  uncinariasis,  about  90  per  cent  of  adults ; 
trichuriasis,  about  70  per  cent  of  adults ;  filariasis,  about 
50  per  cent  of  adults  over  thirty  years.  2.  Treponema 
infections :  f rambesia,  yaws,  all  native  children  have  it, 
have  had  it,  or  Avill  contract  it.  3.  Eye  infections:  (a) 
acute  diplococcic  conjunctivitis,  affects  Avhole  villages  if 


204  TROPICAL    SURGERY   AXD    DISEASES 

not  controlled;  (b)  clironic  granular  conjunctivitis,  30 
to  60  per  cent  of  children  are  affected.  4.  Skin  infec- 
tions: tricliopylitosis  corporis,  about  40  per  cent  of 
adults;  cliromophytosis,  about  40  per  cent  of  adults.  5. 
Common  surgical  conditions :  deep  abscesses,  large  ul- 
cers, and  elephantiasis. 

Guam.- — Americans :  dengue,  dysentery  and  furuncu- 
losis.  Chamorros :  worm  infections,  hookworms,  ascaris 
and  whipworms :  dysentery  and  intestinal  infections  of 
children,  tuberculosis,  epidemic  asthma  (  guha),  syphilis 
(gangosa),  pneumonia,  and  leprosy. 

Malaria 

Malaria  is  possibly  the  most  important  disease  of  the 
world  in  general,  and  Ross'"  statistics  show  that  it  is 
the  most  important  disease  of  the  Tropics.  As  a  rule 
about  one-third  of  the  population  of  malarious  countries 
suffer  from  attacks  every  year,  even  100  per  cent  of  the 
children  of  very  malarious  regions  may  show  either  par- 
asites or  splenic  enlargement.  AVhile  the  case  mortality 
is  only  about  0.5  per  cent,  the  total  mortality  runs  from 
10  to  15  per  1.000 :  in  India  it  is  estimated  that  malaria 
is  responsible  for  about  1,300,000  deaths  each  year. 
Again,  malaria  so  comiDlicates  other  diseases  that,  espe- 
cially in  surgical  cases,  one  must  be  prepared  for  the 
possibility  of  an  explosion  of  latent  malaria  follo^\ing 
the  trauma  of  an  operation,  as  is  also  the  case  at  times 
in  chronic  alcoholism  and  syphilis.  Ten  years  after  the 
discovery  of  the  cause  of  malaria  by  Laveran  (1880),  we 
were  in  the  dark  as  to  the  method  of  transmission  of  the 
parasite  and  it  was  not  until  1899  that  Sir  Eonald  Ross 
proved  the  mosquito  transmission  for  man,  Avhich  was 
subsequent  to  the  Italian  experiments  in  1898.  Ross  ob- 
serves that  although  fifteen  years  have  elapsed  since 
the  knowledge  of  the  mode  of  transmission  of  malaria 
was  obtained,  yet  not  more  than  one-tenth  of  the  im- 


AXSWEPri    TO    QUESTIOXXAIEE  205 

provement  of  health  has  heen  effected  which  Avas  pos- 
silDle  of  accomplislnnent  had  mankind  put  its  heart  into 
tlie  iDrohlem  of  malaria  eradication. 

Malaria:  Prevalence  as  Shown  by  Blood  Examinations; 
Fever  Due  to  Malaria  Following  Operations 

Agea,  Ixdia." — Malaria  is  the  most  prevalent  disease 
in  India  and  has  for  the  whole  population  a  heav^'  death 
rate  either  directly  or  indirectly'  as  complicating  other 
diseases.  It  is  most  prevalent  in  the  months  of  July, 
August,  September,  October,  and  Xoveml^er,  that  is,  in 
the  months  of  the  rains  or  just  following  the  rains.  The 
amount  differs  from  year  to  year.  Given  good  ^Drodue- 
tive  years  ^yit}l  cheap  food  and  the  general  population  in 
healthy  condition  and  normal  rains,  there  is  not  usually 
an  excessive  amount  of  malaria ;  but  given  bad  years, 
foodstuffs  scarce,  famine  and  jDoor  nutrition,  and  hea^-A^ 
rains  on  the  top  of  this,  malaria  is  usually  excessive  and 
has  a  high  death  rate.  OAAdng  to  the  measures  being- 
taken  all  over  India  in  combating  malaria,  it  is  being 
gradually  reduced  and  with  improved  sanitation,  better 
drainage,  the  i^roiDhylactic  issue  of  quinine  and  the  edu- 
cation of  the  masses  it  is  hoiDed  to  greatly  lessen  the 
amount  of  malaria  year  by  year.  AVe  do  not  find  ma- 
larial fever  as  a  rule  complicating  operations  very  much. 
In  our  Agra  experience  it  is  rare. 

HoxGKOXG,  Chixa."- — Extremely  prevalent ;  chiefly  be- 
nign. However,  malignant  tertian  forms  are  not  uncom- 
mon after  operations  and  after  confinement. 

Africa.*''  ^'* — Have  no  European  patients.  Tlie  adult 
native  who  has  been  reared  in  a  fever  district  apj)ears 
to  have  acquired  a  certain  inununity  to  malaria  and  is 
but  rarel}'  troubled  with  it,  a  native  from  a  nonf ever  dis- 
trict, however,  is  just  as  susceptible  to  fever  as  a  Eu- 
ropean if  exposed. 

Ceylox.' — Malaria   is  uncommon  in   Colombo.     It   is 


206  TEOPICAL    SI'RGERY    AXD    DISEASES 

very  common  in  outlying  districts  :  have  very  seldom  seen 
malaria  after  operations, 

FoEMOSA.^ — Very  prevalent.  Estivoantunnial,  tertian, 
quartan,  all  common.  Parasites  easily  found  in  the 
blood:  no  doubt  the  fever  that  occurs  after  operations 
sometimes  is  due  to  malaria. 

KoREA.^ — Malaria  very  frequent  (microscopic  diag- 
nosis) :  in  about  -iO  per  cent  of  the  children,  microscopic 
diagnosis  in  doubtful  cases :  none  seen,  clinical  or  other- 
wise in  Kangkai  Avhich  is  in  the  extreme  North  among 
the  mountains.  The  widesxDread  use  of  quinine  has  re- 
sulted in  a  great  decrease  in  the  prevalence  and  severity 
of  the  disease. 

Samoa.^ — Malaria  does  not  exist  in  Samoa  nor  has 
careful  search  revealed  the  presence  of  any  species  of 
the  family  Anophelina?. 

Guam.- — Xo  malaria  exists  on  the  island. 

Prevalence  of  Opium  or  Other  Drug  Habits  and 
Alcoholism 

BuEMA.^"— Opium  eating  is  i3revalent  among  the  lower 
class  Burmans  and  Chinese  in  the  larger  toA^ms.  The 
cocaine  habit  is  becoming  so  among  the  same  classes.  Al- 
coholism is  not  iDrevalent.  Morphine  is  largely  adminis- 
tered by  injection.    Opium  and  cocaine  by  the  mouth. 

IxDiA." — After  the  age  of  forty  a  small  percentage  of 
the  people  become  addicted  to  taking  opium.  They  gener- 
ally start  the  habit  for  the  cure  of  certain  diseases  such  as 
chronic  diarrhea,  asthma,  bronchial  catarrh  and  diabetes. 
Opium  is  frequently  given  to  children  to  quiet  them.  The 
tobacco  liabit  is  general.  Bhang  is  generally  used  by 
higher  castes  especially  Brahmans.  Alcoholism:  Peo- 
ple generally  are  sober.  Among  the  lower  castes  the 
habit  is  more  general.  Among  the  educated  Indians  the 
habit  is  increasino'. 


ANSWERS    TO    QUE.STIOXXAIBE  207 

HoxGKOxG." — Opium  ]ia1)it  distinctly  on  tlie  decline 
among  Chinese ;  alcohol  on  the  increase. 

SoocHOw,-^  PixG  Yix,^-  Chixa. — Opium  habit  is  the 
curse  of  the  people  but  no  worse  than  in  any  other  place 
in  China.  It  is  easy  to  break  the  average  smoker  by  sub- 
stitution of  another  form  and  gradually  reducing.  We 
have  over  thirty  of  this  class  in  our  wards  all  the  time 
now.    Alcoholism  is  quite  common. 

Afkica.^* — Cannabis  Indica,  native  name  ''Dacha,"  is 
smoked  by  many  tribes ;  no  reports  of  opium  being  used. 

Ceylox.^ — Opium  hal3it  is  not  very  common  and  only 
occurs  among  people  who  are  suffering  from  some  in- 
curable chronic  maladies  such  as  inoperable  cancer,  dia- 
betes, etc.  A  certain  i^roportion  of  people  suffering  from 
gallstones,  and  stones  in  the  kidney,  who  refuse  opera- 
tive treatment  also  take  to  it.  Alcoholism  is  common 
among  the  laboring  classes  and  chiefly  in  large  towns.  It 
is  also  common  among  the  well-to-do  classes. 

For:viosa.^ — Opium  smoking  is  very  connnon.  Also 
some  morphine  ^^ctims  who  use  the  hypodermic  syringe. 
Alcoholism  is  not  very  common  among  the  Chinese.  The 
Japanese  and  also  the  aborigines  are  fond  of  the  bottle. 

KoEEA.^ — The  Korean  medical  association  called  atten- 
tion to  the  prevalence  of  the  opium  habit  in  Korea  and 
that,  contrary  to  laAv,  there  was  knoAvn  to  be  a  good  deal 
of  traffic  in  this  drug  carried  on  by  druggists  of  various 
nationalities.  This  was  officially  i)resented  to  the  gov- 
ernment in  Chosen  and  was  favorably  received.  For- 
merly very  rare,  recently  fairly  common.  Alcoholism 
generally  stated  as  moderately  connnon,  excessive  drink- 
ing is  not  the  rule.  Reid  adds  and  several  confirm  that 
drinking  is  more  prevalent  among  the  farmer  class;  he 
probably  means  "plain  drunks"  on  the  street.  Curell 
estimates  that  60  per  cent  of  men  drink  to  some  extent 
and  adds  that  liver  complications  are  rather  common; 
others  report  liver  cases. 


208  TROPICAL    SURGERY    AXD    DISEASES 

Samoa.^ — Alcoholism  among  the  natives  is  practically 
miknown.  A  law  of  the  land  prohil)its  the  sale  or  giving 
of  alcohol  to  the  native  and  it  has  been  well  enforced. 
Drug  habits  are  practically  nnkno^^^l  in  this  little  com- 
mnnity  because  of  a  law  which  forbids  the  importation 
of  drugs  or  patent  medicines  except  by  express  written 
permission  of  the  medical  government;  a  law  which  is 
capable  of  great  good  in  any  community. 

Gtuam.- — There  is  no  opium  or  other  drug  habit  in  the 
native  population,  and  the  importation  of  drugs  is  under 
the  supervision  of  the  health  officer  of  the  island.  The 
natives  drink  "tuba,"  the  sap  from  the  buds  of  the  cocoa- 
nut  tree;  this  is  generallj^  allowed  to  ferment,  but  at 
times  is  taken  before  fermentation  takes  place.  The  use 
of  ''tuba"  is  common.  There  is  also  a  certain  amount 
of  distilling  of  the  fermented  "tuba"  going  on,  but  this 
is  prohibited  by  the  government  and  those  engaged  in 
the  manufacture  are  punished  when  detected.  The  use 
of  this  spirit  is  not  very  general.  There  is  some  use  of 
beer,  Avhisk^^,  and  gin,  but  the  amount  is  not  great  and 
the  native  can  be  called  a  temperate  individual. 

Surgical    Tuberculosis:    Pulmonary,    of   Bones,    Joints, 

Tendons,  Peritoneum,  Skin,  Genitourinary  Organs 

and  Intestines;  Frequency  of  Pott's  Disease; 

Public   Antituberculosis   Measures 

Burma"  axd  Agra,^  Ixdia. — Tuberculosis  of  all  tissues 
except  the  skin  is  not  uncoimnonly  met  with.  Pott's  dis- 
ease is  rare.  Lupus  is  practically  unknown.  Tubercu- 
losis of  the  testes  is  rare.  Tuberculous  diseases  of  the 
intestine  are  probably  much  more  common  in  natives 
than  in  adults  of  European  countries  and  appear  to  be 
on  the  increase.  Pulmonary  tuberculosis  is  common  and 
is  certainty  on  the  increase.  Tuberculosis  of  bones  and 
joint's  also  is  very  coimnon  and  roughly  accounts  for 
about  20  iDer  cent  of  the  admissions  on  the  surgical  side. 


ANSWERS    TO    QUESTIONNAIRE  209 

Tuberculosis  of  the  g-enitourinary  organs  forms  about  1 
per  cent  of  the  admissions  in  the  hospitals. 

SoocHOW^  AND  Ping  Yin^-  and  Wenchow/'^  China. — 
Tuberculosis  is  the  most  common  of  all  diseases  and  the 
curse  of  the  country;  there  is  no  form  but  what  is  met 
with.  Patients  respond  well  to  modern  treatment,  but 
this  can  not  be  given  to  every  patient. 

Africa.^"-" — Pulmonary  tuberculosis  common  among 
natives  living  in  proximity  to  Europeans.  Whether 
Pott's  disease  is  common  or  not  is  doubtful.  It  is  prob- 
able that  a  deformed  child  would  be  destroyed,  if  living 
in  outside  districts. 

Ceylon.^ — Pulmonar}^  tuberculosis  is  common  among 
the  poorer  classes  in  towns.  Tuberculosis  of  the  bones, 
joints,  tendons,  peritoneum,  skin,  genitourinary  organs, 
and  intestines  is  very  uncommon ;  not  more  than  two  or 
three  cases  of  each  are  seen  during  the  year. 

Formosa.® — Tuberculosis  very  common,  especially  pul- 
monary. Tuberculous  cervical  glands  very  common. 
Not  very  much  tuberculosis  of  bone  and  joints  nor  of 
tendons.  Lupus  not  seen.  Tuberculosis  of  the  cecum  is 
not  infrequent;  is  often  associated  with  chronic  intus- 
susception which  is  operated  upon.  Pott's  disease  is 
very  common.  Tuberculosis  of  the  testes,  epididymis, 
vas  deferens,  prostate,  and  bladder  occasionally  met  with. 

Korea.'' — Surgical  tuberculosis:  tuberculosis  of  all 
kinds  is  quite  common,  especially  of  bones.  Many  of  the 
cases  had  sequestra.  Joints:  no  definite  pathologic 
studies  have  been  made,  and,  while  tumor  albus  is  fairly 
common,  the  later  stages  are  masked  by  the  secondary 
infection  incident  to  acupuncture.  Tendons:  no  report. 
Peritoneum:  many  cases  seen.  Skin:  some  cases  recog- 
nized and  probably  a  good  many  overlooked.  Pott's  dis- 
ease: quite  frequent.  Cervical  and  axillary  adenitis: 
abundant;  many  of  these  patients  have  large  tonsils. 

Samoa.^ — Pulmonary  tuberculosis  exists  in  American 


210  TROPIOAL    SURGERY    AND    DISEASES 

Samoa,  about  twelve  cases  having  been  diagnosed  in  the 
past  3'ear  when  about  three  thousand  cases  of  disease 
were  seen.  No  bone  tuberculosis  was  observed  during 
this  period ;  two  healed  joint  cases  were  seen ;  five  tendon 
sheaths,  probably  tuberculous,  were  operated  on.  Tuber- 
culosis of  the  genitourinary  organs  and  of  the  intestines, 
was  not  recognized.  Pott's  disease  is  present,  about 
tw^enty  old  cases  being  scattered  through  the  population. 
Tuberculous  glands  of  the  neck  are  quite  common ;  there 
were  six  operations  for  this  in  the  last  500  operations 
performed. 

GuAM.^ — Pulmonary  tuberculosis  is  very  common  and 
fatal.  Knee-joint  involvement  is  frequent  in  children; 
no  cases  were  seen  in  adults.  The  treatment  by  rest, 
hyperemia  and  good  food  gave  excellent  results  in  the 
hospital.  Tuberculous  involvement  of  the  vertebrae  and 
of  other  bones  and  joints  was  remarkably  infrequent; 
no  new  cases  were  seen  and  there  were  but  few  old  cases 
seen  on  the  island.  Peritoneal  tuberculosis  was  not  com- 
mon. Intestinal  tuberculosis  was  frequent  in  children 
and  there  were  great  numbers  of  cases  of  involvement 
of  the  mesenteric  glands.  Cervical  glandular  disease 
was  common  in  young  adults  and  children. 

Kala-azar 

•  Burma." — Kala-azar  is  practically  unknoA^^l.  It  is  met 
with  from  time  to  time,  but  no  properly  investigated 
case  occurring  in  a  native  of  Burma  has  yet  been  re- 
ported. All  the  cases  seen  here  have  probably  been  im- 
ported cases  from  India  or  Assam. 

PiiS^G  YiisT,  China.^^ — Infantile  type  of  kala-azar  is  ex- 
tremely common.  Have  not  looked  for  the  Leishman- 
Donovan  bodies,  but  the  cases  agree  closely  in  all  their 
clinical  features  A\ith  those  described  by  one  mission  doc- 
tor in  Peking,  Dr.  Graham  Aspland,  by  whom  they  have 
been  isolated.     (See  China  Medical  Journal,  May,  1911.) 


ANSWERS    TO    QITERTIONNATEE  211 

Samoa/ — Kala-azar  ivS  not  found. 
Guam.- — Kala-azar  does  not  exist. 

Syphilis:  Results  with  Ehrlich's  "606"  Treatment 

BuRMA.^°— Syphilis  very  prevalent.  Ehrlich's  "606" 
has  been  tried  on  a  small  scale  with  no  ver^^  gratif3dng- 
results,  as  regards  establishing  immunity  from  the  later 
effects  of  syphilis. 

Agra,  India. ^ — S^^philis  is  fairly  common  and  forms 
about  20  per  cent  of  the  admissions  to  the  hospitals.  The 
majority  of  cases  come  during  the  second  stage  and  third 
stage  of  the  disease;  with  Ehrlich's  "606"  treatment  th,e 
sores  heal  more  rapidly;  the  Wassermann  reaction  is 
sometimes  negative  after  one  injection,  but  always  nega- 
tive after  two.  We  combine  the  treatment  with  mercury 
internally.    We  have  seen  no  ill  results  from  it. 

Hongkong"  and  Ping  Yin,^^  China. — Syphilis  is  very 
prevalent;  606  treatment  a  great  help,  but  not  absolutely 
curative. 

Colombo,  Ceylon.^ — Syphilis  fairly  common  among 
the  to^^m  population;  used  606  in  thirty  cases,  with  very 
gratifying  results.  Treatment  with  mercury  has  been 
continued;  the  results  have  been  particularly  satisfac- 
tory in  phagedenic  ulcerations,  bone  pains  in  joints,  and 
on  secondary  eruptions. 

Samoa.^ — Syphilis  is  not  present.  A  few  cases  came  to 
the  port  three  years  ago,  but  were  deported  before  caus- 
ing any  spread  of  the  infection.  A  few  cases  of  late  and 
of  hereditary  syphilis  have  been  seen,  but  these  were  in 
cases  where  the  original  infection  could  be  traced  to  some 
other  island. 

Korea. ^ — Many  cases  of  s;fphilis  are  seen. 

Guam,- — No  primary  syphilis  was  seen  and  none  exists 
on  the  island.  There  is  an  old  syphilitic  infection  which 
is  very  common,  "gangosa."  Treatment  with  salvarsan 
was  started  in  June  and  had  not  been  carried  far  enough 
to  make  a  report. 


212  TROPICAL    SUEGEPvY   A^'^D    DISEASES 

Typhoid:    Complications,    Percentag-e    of    Perforations, 
Peritonitis,  Osteomyelitis,  Parotitis,  Operations  Made 

Eaxgoox,  Burma. ^- — Typlioid  fairly  common  among 
Europeans  and  natives  of  India  and  Burma.  Mental  af- 
fections have  been  noted  as  a  not  infrequent  complica- 
tion in  natives.  Percentage  of  perforations  is  higher 
among  natives  than  Europeans  owing  to  former  seeking 
medical  aid  late.  Osteomyelitis  and  parotitis  uncom- 
mon. If  perforation  is  recognized  early  enough,  laparot- 
omy is  performed ;  successful  cases  practically  nil. 

Maxila.^^ — For  some  years  after  the  American  occu- 
pation it  was  thought  that  typhoid  was  unusual  in  the 
Philippines.  It  has  been  recognized,  however,  by  army 
surgeons  in  23ractically  every  island  in  the  archipelago. 
This  board  has  been  Avorking  on  the  subject  of  typhoid 
for  two  and  a  half  years  and  has  come  to  the  conclusion 
that  typhoid  is  common  and  ever  present  among  both 
Americans  and  natives  and  is  prol^ably  more  prevalent 
than  it  is  in  the  United  States.  "We  have  investigated 
man}^  ej)idemics,  A  great  many  cases  of  typhoid  in  the 
Phili]Dpines,  both  among  natives  and  whites,  are  mild 
and  atypical  and  can  not  be  recognized  except  by  lab- 
oratory methods.  The  mortality,  of  late  years,  when 
good  facilities  are  available,  is  no  higher  than  in  the 
United  States,  or  about  7  p)er  cent.  Our  experience  ^^dth 
paratyphoid  is  limited  to  two  cases  in  which  we  isolated 
the  organism  from  the  blood.  About  15  per  cent  of  Phil- 
ippine tyiDhoids  have  hemorrhages,  probably  due  to  in- 
testinal parasites. 

Agra,  Ixdia.^ — Typhoid  is  common  among  Europeans 
in  India,  but  rare  among  adult  natives.  It  is  becoming 
less  common  among  Euroj)eans  as  more  precautions  are 
taken.  Antityphoid  inoculation  and  the  isolation  of 
"carriers"  have  done  much  to  lessen  its  frequency. 
Among  comiDlications,  perforation,  peritonitis,  osteomy- 
elitis,  and  parotitis   are   rarely  seen.     Hemorrhage   is 


ANSWERS    TO    QLIESTlOiXNAHlE  213 

more  common,  and  so  arc  tliroml)osis  and  periostitis. 

Hongkong,  China." — Cholecystitis,  gallstone  and  bil- 
iary sand  not  iinconmion  after  typhoid.  However,  this 
disease  is  not  very  connnon  in  Hongkong  unless  im- 
ported, and  is  mild  in  type. 

Colombo,  Ceylon.'^ — During  1912  two  cases  of  typhoid 
perforation  were  operated  on  and  recovered;  no  statis- 
tics of  the  general  prevalence  of  typhoid  fever  and  its 
complications  available. 

Shoka,  Formosa.® — Typhoid  is  fairly  connnon.  Have 
seen  severe  hemorrhage  from  the  bowel ;  one  case  of  per- 
foration operated  on  unsuccessfully. 

Samoa.^ — Typhoid  is  not  present. 

Guam.- — There  is  no  typhoid  on  the  island. 

Dysentery:  Amebic,  Bacillary,  Perforation  of  Intestine, 
Peritonitis;  Hemorrhage  from  the  Bowel.    Appendi- 
citis: Operations  for,  Results.     Appendicostomy: 
Is  Dysentery  Becoming  Less  Frequent  and  Less 
Serious  Under  Modern  Conditions?  Relative 
Percentage  Among  Natives  and  Europeans 

Rangoon,  Burma."' — Dysentery  is  one  of  our  common- 
est diseases  and  has  a  prominent  place  in  all  death  statis- 
tics of  Burma.  Both  amebic  and  bacillary  dysentery  are 
met  with,  the  former  being  the  more  common.  Under 
the  head  of  bacillary  dysentery  it  is  almost  certain  that 
more  than  one  disease  is  included  at  the  present  time. 
Among  the  cases  described  as  dysentery  are  many  cases 
of  ulcerative  colitis  which  are  probably  neither  amebic 
nor  bacillary  dj^sentery;  such  cases  are  very  frequently 
returned  as  "chronic  diarrhea,"  owing  to  their  pro- 
longed course  and  slight  clinical  evidence  of  ulceration 
of  the  large  bowel.  At  autopsy,  the  ulcerations  found 
are  usually  very  shallow  and  are  very  minute  though 
numerous. 

Agra,  India." — Dysentery  is  common  in  India,  Init  nn- 


214  TPtOPiaU.    SURGERY    AXD    DISEASES 

der  modern  conditions  we  do  not  see  as  many  serious 
cases  as  formerly.  In  the  mild  cases  the  saline  treatment 
(magnesia  sulphate)  is  the  most  satisfactory,  and  the 
ipecac  treatment  in  the  more  serious  cases.  Have  not 
seen  appendicitis  as  a  complication  and  have  i^erformed 
appendicostomy.  It  is  more  common  among  natives  than 
Europeans,  but  it  is  much  less  common  than  formerly 
among  native  troops  and  prisoners  owing  to  the  im- 
proved sanitary  conditions.  It  is  rare  to  see  a  severe 
case  among  the  better  class  of  Europeans. 

HoifGKOXG."- — In  private  practice  at  least  90  per  cent 
of  the  dysentery  seen  is  amebic.  The  routine  treatment 
is  salines  by  mouth  and  quinine,  nitrate  of  silver,  and 
boric  acid  injections  per  rectum  given  in  the  genupec- 
toral  position.  In  relapsing  cases  of  amebic  dysentery 
salines  often  fail  and  ipecac  is  then  given.  Appendicitis 
is  connnon  after  any  affection  of  the  colon ;  have  had  no 
cases  suitable  for  appendicostomy. 

Weistchow^^  axd  Pixg  Yix,^-  Chixa. — Dysentery  exceed- 
ingly common,  endemic  most  of  the  year  and  epidemic 
each  summer  and  autumn.  AAliole  villages  often  carried 
off  by  an  epidemic.  Diet,  albumin  water.  Ipecac  gives 
the  best  therapeutic  results  when  properly  administered. 
Rectal  injections  of  quinine  also  valuable.  Perforation, 
peritonitis,  or  severe  hemorrhage  in  dysentery  not  seen. 

Colombo,  CEVLOiSr.'' — One  case  of  appendicostomy  in  a 
very  severe  type  of  bacillary  dysentery  where  antidysen- 
teric  serum  had  been  tried  without  benefit.  Although 
the  patient  was  relieved  of  the  more  urgent  s^inptoms, 
he  died  from  s^Tinptoms  of  septicemia  on  the  third  day. 
In  three  cases  of  chronic  colitis  appendicostomy  was  done 
A^ith  good  results.  Have  never  seen  perforation  dysen- 
tery, nor  appendicitis  following  dysentery.  Dysentery 
is  more  connnon  during  the  dry  seasons  following  wet 
weather.  It  is  more  common  among  natives,  but  Euro-, 
peans  have  a  more  severe  type. 


ANSWERS    TO    (^TESTION  XAIUE  215 

Shoka,  Formosa.^ — Dysentery  very  eominoii ;  hoth  ame- 
bic and  bacillary;  treatment  ])y  salines  preferred  to 
ipecac  or  calomel;  few  of  the  complications  except  stric- 
ture of  the  rectum  in  one  child ;  appendicostomy  not  tried. 
With  our  new  Avater  supply  dysentery  is  becoming  much 
less  frequent;  next  to  malaria  it  is  perhax)s  the  com- 
monest disease. 

Samoa.^ — Dysentery  is  common;  type  bacillary,  exact 
organism  not  determined.  Amebas  have  not  been  found. 
Predisposing  causes  seem  to  be  mainly  ingestion  of  de- 
caying food  or  too  great  an  amount  of  food  during  times 
of  feasting.  Two  clinical  types :  iirst,  semiacute,  ten 
stools  a  day,  slight  amount  of  blood,  well  in  a  feAv  days 
after  simple  catharsis  and  starvation,  by  far  the  usual 
type;  second  or  blood  type,  twent}'^  stools  a  day,  pain, 
tenesmus,  blood,  pus,  mucus,  sometimes  almost  pure 
blood  in  considerable  quantities,  prostration  moderate. 
These  cases  get  well  two  to  three  weeks  after  administra- 
tion of  ipecac  in  large  doses.  The  European  is  careful 
of  his  diet  and  practically  never  contracts  either  form 
of  dysentery.  The  European  who  lives  with  the  native 
is  liable  to  the  same  forms.  Death  from  this  cause  alone 
is  very  rare  in  cases  treated,  but  in  cases  left  to  the 
native  doctors  death  is  common,  for  they  insist  upon 
feeding  their  patients.  They  believe  that  frequent  stools 
demand  frequent  feeding. 

KoREA,^ — Amebic  dysenter^^  is  not  uncommon  and  diar- 
rhea of  other  kinds  is  very  common  in  the  summer  time. 
Weir  has  made  definite  search  for  the  amebas  and  has 
found  them  in  a"  few  cases.  Hospital  practice  in  Seoul 
shows  quite  a  number  of  liver  abscess  cases ;  other  com- 
plications infrequent;  appendicitis  rare. 

Guam.- — No  bacillary  dysentery  on  the  island.  Ameinc 
dysentery  is  common.  The  number  of  cases  of  amelnasis 
having  dysenteric  s^anptoms  is  not  relatively  very  great. 
The  incidence  of  dvsenterv  is  nraeli  reduced  since  the 


216  TROPICAL  SURGERY  AND  DISEASES 

introduction  of  a  Avat^r  supjily  and  the  closing  of  the 
okl  surface  avcIIs.  Tln^  infection  is  not  of  a  severe  type 
and  seems  to  be  growing  milder.  The  ordinary  ipecac 
and  opium  treatment  was  the  routine  and  the  results 
generally  were  good;  in  some  of  the  more  severe  cases 
irrigations  with  quinine  also  were  given,  and  cures  gen- 
erally resulted.  Eight  appendicostomies  were  made  ^^-ith 
13erfect  results  in  six  cases;  one  was  improving  when 
last  seen;  one  case  died,  as  the  disease  was  too  far  ad- 
vanced to  expect  any  other  result.  AiDXDendicostomy  or 
cecostomy  as  the  operator  may  desire  is  of  the  greatest 
value  and  amebic  dysentery  in  certain  cases  becomes  a 
surgical  rather  than  medical  disease.  After  a  patient 
has  had  medical  treatment  for  a  reasonable  length  of 
time  without  good  results,  appendicostomy  should  be 
made  and  s(H)n  enough  to  previ^iit  tlie  develoi)ment  of 
ulcerative  conditions  that  are  sure  to  produce  permanent 
injury  to  the  bowel;  several  cases  in  the  service  in  which 
the  ordinary  medical  treatment  was  of  no  apparent  value 
and  where  the  symptoms  suggested  liver  abscess  cleared 
up  perfectly  after  appendicostomy  was  performed.  Xo 
cases  of  perforation  of  the  intestine  were  seen.  Hemor- 
rhage from  the  bowel  Avas  at  times  fairly  severe  but  in 
no  case  dangerous.  No  peritonitis  or  appendicitis  was 
seen  that  was  due  to  ameba.  The  disease  is  very  much 
more  frec[uent  among  natives  tlian  Americans  OAving  to 
the  precautions  taken  by  the  latter.  It  is  difficult  to  state 
percentages,  but  relatively  not  one  case  occurs  in  the 
American  to  ten  in  the  natiA'e. 

Intestinal  Parasites  and  Intestinal  Worms:  Have  Sys- 
tematic Examinations  of  the  Stools  of  the  Natives 
in  Large  Numbers  and  in  Different  Places  in 
the  Country  Been  Made? 

Raxgoox,   Bur^ia."^" — Intestinal  A\'orms   are  A'ery  fre- 
quent.    Xo   systematic   examinations  have   been  made. 


ANSWERS    TO    QUESTIONNAIRE  217 

Round  worms  in  fair  iiuiiiIxTs  are  almost  always  present 
in  Burmese;  one  or  two  cases  of  intestinal  ol)struction 
caused  by  large  masses  of  these  worms  have  been  met 
Avith.  Ankylostoma  infection  "of  a  minor  degree  is  very 
connnon.     Tenia  inf(^ctions  are  rare. 

SwEBO,  Burma/* — These  observations  were  made  on 
prisoners  and  also  from  those  attending  in  the  liospitals. 
They  are  all  male  adults.  Out  of  2000  cases  examined 
parasites  were  found  in  1048  of  them,  giving  a  percentage 
of  52.  Of  these  257  were  ankylostoma  duodenale,  253 
ascaris  lumbricoides ;  243  trichocephalus  dispar;  170 
rhabdonema  intestinale;  89  ameba  coli;  29  oxyuris  ver- 
niicularis ;  5  tenia  saginata  and  2  were  tenia  solium.  Re- 
sults with  santonin  on  100  new  admissions  into  jail:  Each 
prisoner  who  was  in  good  health  when  he  was  admitted 
into  the  jail  was  given  santonin,  5  grains,  followed  by  a 
saline  purge.  Of  these  82  per  cent  had  worms,  51  of 
them  passed  2  worms  each,  12,  1  worm,  11,  3  worms,  and 

8  passed  4  worms.  The  longest  of  these  worms  was  14 
inches,  and  the  shortest  was  6  inches.    The  average  was 

9  inches.  Results  with  100  old  admissions  in  the  jail : 
AVith  another  100  prisoners  already  in  jail  and  selected 
from  a  healthy  set  of  men,  I  obtained  the  folloA\ing  in- 
formation. Of  these  89  passed  worms,  30  of  them  j)assed 
1  worm  each;  26,  2;  18,  4;  and  15  passed  3  worms.  The 
longest  of  the  worms  measured  15  inches  (female)  and 
the  shortest  4  inches  (male).  The  average,  7  inches.  Re- 
sults Avith  500  prisoners :  Fifty  prisoners  were  selected 
from  time  to  time  from  the  different  sections  in  the  jail. 
The  observations  extended  over  a  year  and  the  results 
were  as  follows:  109  passed  worms,  38  of  them  1;  27,  2; 
22,  3 ;  6,  4 ;  6,  5 ;  5,  6 ;  3,  9 :  1,  7 ;  and  one  passed  8  worms. 
Remarks :  These  observations  show  that  ankylostoma 
duodenale  was  the  most  prevalent,  then  ascaris  lumbri- 
coides, then  trichocephalus  dispar  and  then  rhabdonema 
intestinalis.     The  large  number  of  ankylostoma  passed 


218  TROPICAL    SURGERY    AND    DISEASES 

was  due  chiefly  to  the  climate,  which  was  exceedingly 
damp  throughout  the  year,  but  especially  during  the 
rains.  The  prevalence  of  ascaris  lumbricoides  and  tricho- 
cephalus  dispar  requires  no  comment  as  they  are  very 
common  in  the  Tropics.  Rhabdonema  intestinalis  is  not 
uncommonly  found  in  the  Tropics :  these  parasites  w^ere 
most  prevalent  at  the  end  of  the  rains,  September  and 
October,  and  then  during  the  rains,  July  and  August. 

Shoka,  Formosa.® — ^Intestinal  parasites  and  worms  ex- 
ceedingly common.  Amebic,  malarial,  and  bacillary  dys- 
enteries are  all  very  common.  Ascaris,  trichuris,  hook- 
worm, oxyuris  are  common;  only  one  case  of  tapeworm. 

Samoa.^ — ^Intestinal  parasites :  very  common ;  ascaris, 
uncinaria,  trichuris,  oxyuris  vermicularis.  It  is  prob- 
able that  every  native  child  carries  the  ascaris,  that  every 
adult  carries  the  hookworm  and  most  of  them  the  trich- 
uris. A  very  few  children  have  the  ox^airis  vermicularis. 
An  examination  of  seventy  men,  picked  for  their  good 
hygienic  surroundings,  all  of  them  being  members  of  the 
native  guard  who  live  in  barracks,  showed  that  all  of 
them  carried  hookworm ;  that  nearly  all  had,  in  addition, 
the  AvhipAvorm  and  that  a  few  had  the  ascaris.  About 
five  hundred  examinations  of  the  general  adult  popula- 
tion scattered  throughout  the  island  shoAved  practically 
the  same  proportion.  It  was  a  matter  for  comment  when 
the  stool  of  a  child  failed  to  show  eggs  of  ascaris.  While 
large  numbers  thus  carry  one  or  more  intestinal  para- 
sites, only  a  small  percentage,  say  10  per  cent  of  the 
adult  population,  show  marked  effects  from  this  cause, 
probably  because  of  the  abundance  of  food  and  small 
amount  of  hard  work,  conditions  which  make  up  for  the 
loss  occasioned  by  the  parasites.  However,  practically 
every  case  of  illness  as  a  routine  measure  Avas  treated 
for  intestinal  parasites  in  order  to  facilitate  recovery  to 
convalescence.    Neglect  of  this  measure  would  at  times 


ANSWERS    TO    QUESTIONNAIUli  219 

delay  tlie  effect  of  treatment  for  otlier  medical  or  sur- 
gical conditions. 

Korea. ° — Ninety-nine  per  cent  of  Koreans  have  intes- 
tinal worms ;  cliiefi}^  ascaris.  No  systematic  examination 
of  stools. 

GuAM.-^ — Ascaris,  whipworms,  and  hookworms,  both 
varieties,  were  found  in  almost  100  per  cent  of  the  na- 
tives. In  1910  the  school  children  of  Agat  were  brought 
to  Agaiia  for  examination  and  treatment.  Of  121  chil- 
dren, 119  were  positive  to  hookworms  upon  first  exam- 
ination and  the  whole  number  upon  the  second  examina- 
tion. The  other  worms  were  about  the  same.  In  this 
year  all  of  the  school  children  of  the  island  were  taken 
into  the  hospital  between  January  1  and  July  1  for  worm 
treatment,  and  observation  gave  practically  the  same 
results.  Systematic  stool  examinations  have  been  made 
and  recorded  for  some  years.  All  patients  entering  the 
hospital  had  stool  examinations  made  as  a  matter  of 
routine.  Salines  were  given  as  a  rule  and  the  stool  ex- 
aminations were  made  a  few  minutes  after  a  movement 
was  obtained.  There  was  no  rule  about  the  number  of 
smears  examined,  but  if  one  was  negative  the  examina- 
tion Avas  generally  carried  to  three  or  four  slides  be- 
fore the  case  was  considered  negative.  In  the  negative 
cases  the  examinations  were  made  on  two  or  more  daj^s. 
This  work  was  very  carefully  done.  Balantidium  was 
found  to  be  fairly  common.  This  was  worked  up  dur- 
ing the  past  year  and  the  infection  found  to  be  more  fre- 
quent than  had  been  anticipated.  One  case  of  death  was 
attributed  to  this  cause  as  no  other  factor  could  be  found 
at  autopsy.  No  tape  worms  were  encountered  in  the  time 
under  consideration. 

''Tropical  Liver"  and  Liver  Abscess 

Rangoon,  Burma." — Liver  abscess  is  of  moderate  fre- 
quency; until  the  last  two  years  the  usual  treatment  had 


220  TROPICAL  SURGERY  AND  DISEASES 

been  to  open  freely  and  drain  in  the  ordinary  way ;  many 
quite  early  cases  died  as  the  result  of  secondary  septic 
infection.  In  the  early  small  abscesses  the  pus  is  sterile 
so  far  as  the  usual  pyogenic  organisms  are  concerned; 
amebas  can  generally  be  found  if  a  proper  selection  of 
pus  be  made.  In  the  older  abscesses  bacteria  are  gen- 
erally present  together  with  amebas ;  the  bacteria  found 
are  coli,  staphylococcus,  and  pneumococcus.  Consider- 
ing the  relative  proportions  in  the  community  of  natives 
and  Europeans,  there  is  no  doubt  but  that  the  large 
single  tropical  abscess  of  the  liver  is  much  more  common 
among  the  latter.  Ulceration  of  the  appendix  is  found 
in  a  few  cases  of  dysentery  examined  postmortem,  but 
it  does  not  give  rise  to  symptoms  during  life.  Intes- 
tinal hemorrhage  is  common  to  a  slight  degree  in  most 
cases  of  true  dysentery;  in  a  few  cases  of  very  acute 
bacillary  dysentery  hemorrhage  has  been  very  severe, 
and  at  postmortem  the  ulceration  was  insignificant.  Pro- 
fuse hemorrhage  does  not  occur  from  the  large  gan- 
grenous ulcers  so  common  in  amebic  d^^sentery;  the  ves- 
sels are  probably  thrombosed  long  before  they  become 
ulcerated. 

Agra,  India.' — During  1909, 1910,  and  1911,  forty-three 
cases  of  liver  abscess  have  been  treated  in  the  Agra  hos- 
pitals. Twenty  were  operated  on  b)^  the  open  method; 
i.  e.,  incision,  resection  of  rib  if  necessary,  and  drain- 
age ;  of  these,  ten  died ;  many  come  in  with  huge  abscesses 
and  in  a  very  bad  condition  indeed,  some  almost  in  ex- 
tremis. Thirteen  cases  Avere  treated  by  aspiration  and 
the  injection  of  hydrochloride  of  quinine;  of  these,  two 
died.  The  cases  A\^ere  all  large  single  abscesses.  We 
rarely  see  them  before  a  bulging  of  the  side  or  in 
front  is  visible,  but  the  diagnosis  is  usually  established 
by  a  leukocyte  count.  In  all  the  cases  the  histor}^^  of 
dysentery  was  invariably  present.  From  our  statistics 
liver  abscess  is  much  more  common  among  natives ;  that 


ANSWERS    TO    QUESTIONNAIRE  221 

is  because,  for  the  most  part,  our  Agra  hospitals  are 
for  the  admission  of  natives,  hut  it  is  commoner  among 
natives  probal^ty  because  of  neglect  of  early  treatment. 
No  cases  of  appendicitis  associated  with  dysentery  and 
no  cases  of  intestinal  hemorrhage  associated  with  liver 
abscess  were  seen. 

Colombo,  Ceylon." — Liver  abscess  is  not  common  al- 
though dysentery  is  very  prevalent.  It  is  more  com- 
mon among  Europeans  than  among  natives.  Last  year 
twelve  cases  were  operated  on  with  one  death;  of  these 
only  two  cases  occurred  among  natives.  Where  marked 
symptoms  are  present,  indicating  the  location  of  the  ab- 
scess, operation  is  a  simple  matter ;  the  abscess  is  opened 
after  excising  a  portion  of  the  rib  and  shutting  off  the 
pleural  cavity  by  stitches.  Where  no  local  tenderness 
or  bulging  existed,  laparotomy  was  done  and  the  liver 
palpated  with  the  hand  inside  the  abdomen.  An  ab- 
scess located  by  this  method  was  opened  by  resection  of 
a  rib  at  a  subsequent  operation.  In  all  cases  drainage 
tubes  were  inserted  and  the  cavity  freely  drained.  In 
deep-seated  abscesses  where  the  opening  had  to  be  made 
through  a  considerable  thickness  of  normal  liver  tissue, 
bleeding  was  found  to  be  profuse,  and  had  to  be  checked 
by  gauze  which,  was  removed  later  and  the  tubes  in- 
serted. In  ten  cases  the  abscesses  were  solitarj^;  in  two 
cases  multiple.  Irregular  fever,  sweating  and  localized 
tenderness  over  the  region  of  the  liver,  with  increase 
of  liver  dullness  are  the  chief  signs. 

Wenchow,  China.^^ — Liver  abscess  fairly  common. 
Six  cases  operated  on,  all  recovered;  swelling  visible 
in  each  case.    All  had  previously  had  dysentery. 

Shoka,  Formosa.^ — ''Tropical  liver"  occurs  in  for- 
eigners who  live  too  well.  Twelve  al^scess  cases  in  Chi- 
nese. "Where  the  exploring  needle  shows  pus,  incise; 
and  if  the  liver  is  not  adherent  to  the  abdominal  wall, 
stitch  it  to  the  peritoneum  before  opening.     Recoveries 


222  TROPICAL  SURGERY  AND  DISEASES 

about  70  per  cent.  The  abscess  is  generally  solitary  and 
the  pus  sterile;  amebas  not  found.  Cases  generally  do 
not  come  until  there  is  a  sv/elling.  In  niaii}^  cases  no 
antecedent  history  of  dysentery. 

Guam.- — Liver  abscess  and  tropical  liver  are  not  very 
common  considering  the  number  of  cases  of  amebic  dys- 
entery seen. 

KoREA.^- — Liver  abscess  is  fairh^  common;  tropical 
liver,  reported  only  by  Weir. 

Samoa. ^ — ^^Five  cases  of  enormous  chronic  enlargement 
of  the  liver  without  splenic  enlargement  have  been  seen 
just  before  death.  One  of  these  cases  was  explored  with 
needle  in  several  directions  without  obtaining  pus.  No 
autoi^sies  were  possible.  Liver  abscess  has  not  been 
found. 

Cancer 

EA]srG00]sr,  Burma. ^" — Carcinoma  is  considerably  less 
frequent  thou  in  England.  Breast,  penis,  and  uterus  are 
the  parts  most  frequently  affected.  Xo  precancerous 
stage  observed.  Ejoithelioma  of  the  cheek  is  not  uncom- 
mon and  is  probably  excited  by  betel-chewing.  Epithe- 
lioma of  the  penis  is  common  among  Chinamen.  Car- 
cinoma of  the  breast  is  not  so  common  among  natives  as 
among  women  of  Europ)ean  countries.  Epithelioma  of 
the  tongue  is  exceedingly  rare  among  natives ;  two  cases 
seen  during  six  years  of  hospital  experience.  On  the 
other  hand  primary  carcinoma  of  the  liver  appears  to 
be  very  much  more  common  among  natives  both  Indian 
and  Burman  than  among  Europeans.  This  cancerous 
growth  of  the  liver  may  be  mistaken  for  liver  abscess, 
as  it  gives  rise  to  fever  and  i^ain.  Carcinoma  of  the 
rectum  is  practically  unknown. 

Agra,  Ixdia.' — Carcinoma  is  common  in  India  and 
more  cases  are  seen  now  than  formerly  because  the  vil- 
lage people  resort  to  hospitals  more  frequently.  Can- 
cer occurs  in  all  organs  and  parts  of  the  body  in  about 


ANSWERS    TO    QUESTIONXAIRE  22.^ 

the  same  proportion  here  as  in  Europe.  Epithelioma  of 
the  penis  and  tongue  is  excessively  prevalent. 

Ping  Yin,^-  Soochow,^  and  AVenchow,^''  China. — Car- 
cinoma fairly  common ;  regions  chiefly  affected  are  breast, 
rectum,  lips,  cheek,  uterus,  penis,  skin  of  back  and  esoph- 
agus. In  many  cases  the  cancer  has  been  preceded  by  a 
small  pimple,  papule,  or  sebaceous  cyst  often  of  many 
3^ears'  duration. 

Johannesburg,"  Africa. — Malignant  disease  does  not 
appear  to  be  so  common  among  natives  as  among  Eu- 
ropeans. 

Colombo,  Ceylon.^ — In  males  carcinoma  of  the  cheek, 
upper  and  lower,  jaws  is  common.  Next  in  frequency 
is  carcinoma  of  the  penis,  then  carcinoma  of  the  tongue. 
In  females  cancer  of  the  uterus  and  cancer  of  the  breast. 
A  precancerous  stage  has  often  been  noted  in  connection 
with  cancer  of  the  cheek  in  the  form  of  leukoplakial 
patches. 

Shoka,  Formosa.^— Carcinoma  is  common  in  the  mam- 
ma, cervix  uteri,  upper  jaw,  penis,  sometimes  in  old 
scars,  and  lip. 

Guam.-— Carcinoma  of  the  uterus  Avas  seen  in  one 
woman,  and  it  was  not  found  at  any  of  the  postmortem 
examinations. 

Eangoon,  Burma.^° — Sarcoma  not  frequently  met  with, 
abdominal  sarcoma  springing  from  the  pelvis  has  been 
most  often  observed.  Sarcoma  occurs  in  all  regions  of 
the  bod}",  but  it  is  most  common  in  the  cervical  region. 

Agra,  India." — ^AVe  see  many  cases  of  sarcoma,  mainly 
of  the  long  bones,  jaws,  nose,  orbit  and  also  of  all  parts 
of  the  body  where  such  tumors  usually  occur. 

SoocHOw""  AND  AYenchow,^"'  China. — Sarcouia  is  very 
frequent,  involving  upper  jaw,  long  l)ones,  eye,  foot,  tes- 
ticle, parotid. 

CoLo:\iBO,  Ceylon.'^ — Sarcoma  is  uncommon.  It  usually 
occurs  in  connection  witli  the  upper  jaw. 


224  TROPICAL  SURGERY  AXD  DISEASES 

Shoka,  Formosa.® — Sarcoma,  fairly  common,  particu- 
larly so  in  the  neck,  also  at  lower  end  of  the  femnr,  and 
npper  end  of  hnmerns. 

KoREA.^ — Cancer  and  sarcoma,  fairly  common,  bnt  not 
so  prevalent  as  in  the  United  States.  The  rarity  of  can- 
cer of  the  lip  in  a  race  where  pipe  smoking  is  almost 
miiversal  among  men  and  not  uncommon  among  women 
is  rather  noticeal^le.  The  frequency  of  breast  cancer 
among  women  whose  breasts  are  so  exposed  to  the  sun 
and  various  irritants  is  easy  to  understand.  Ovarian 
cysts  are  quite  common.  Every  one  reports  fibroids  as 
connnon  and  in  addition  several  have  had  cases  of  car- 
cinoma of  both  the  cer\ux  and  the  body  of  the  uterus. 
A  number  Avith  experience  elsewhere  state  it  as  their 
opinion  that  the  frequency  of  this  condition  is  about  as 
in  Europe  and  America. 

Samoa. — Sarcoma  not  observed. 

Guam. — No  cases  of  sarcoma  were  seen. 

Diseases  of  Women  Among-  Natives:  Ovarian  and  Uterine 

Tumors;    Puerperal    Injuries;    Native 

Method  of  Accouchement 

Raxgoox,  Buema.^'' — Ovarian  and  uterine  tumors  are 
of  moderate  frequency.  Genital  and  pelvic  diseases  of 
women  are  frequent,  chiefly  the  result  of  venereal  infec- 
tion or  sepsis  following  childbirth  or  abortion.  Results 
of  puerperal  injuries  are  common  in  the  district.  Native 
methods  of  accouchement  are  primitive  and  barbarous. 

Agra,  Ixdia.^ — In  the  special  hospitals  for  Avomen  in 
Agra  Ave  see  a  large  number  of  cases  of  oA^arian  tumors; 
tAA^enty  to  thirty  cases  are  operated  on  annually.  They 
are  usually  A^ery  large  tumors  of  the  oA^ary  or  the  broad 
ligament  and  frequently  AAith  many  adhesions ;  the  cases 
almost  alAA'ays  do  Avell.  Uterine  tumors  are  less  common, 
but  many  cases  of  small  and  large  fibroids  are  seen. 
Genital  and  peh^ic  diseases  are  A^ery  common  among  na- 


AiS^SWERS    TO    QUESTIOXXAIRE  225 

tive  women  and  there  is  a  large  ont-patient  and  in-patient 
department  here  under  three  English  qualified  women 
physicians,  as  many  of  the  cases  are  "purdah  nashin" 
ladies.  As  regards  the  native  method  of  accouchement, 
no  cleanliness  whatever  is  observed  during  and  before 
labor;  the  woman  is  made  to  strain  almost  from  the  on- 
set of  the  lal^or  pains.  The  usual  posture  is  the  sitting 
one,  and  the  placenta  is  in  most  cases  extracted  by  the 
ignorant  midwife  directly  after  the  birth  of  the  child. 
Endeavors  are  now  being  made  to  educate  these  ' '  Dhais ' ' 
or  native  midwives  in  antiseptic  and  modern  midwifery, 
and  excellent  work  is  being  accomplished  in  attaining 
this  end.  Cesarean  section  is  performed  from  ten  to 
twelve  times  a  year  in  the  maternity  hospital  here,  al- 
ways for  cases  of  contracted  pelvis,  usually  due  to  osteo- 
malacia or  pronoimced  rickets. 

HoifGKo:N'G." — Ovarian  and  uterine  tumors  common. 

Ping  YiiSr,  Chijsta.^- — Uterine  tumors  are  chiefly  cancer 
of  the  cervix.  Genital  and  pelvic  diseases  of  women 
mainly  syphilitic.  Puerperal  fever  common  and  often 
fatal.  Tetanus  infection  the  result  of  puerperal  injuries. 
Native  method  of  accouchement,  squatting  position,  labor 
rapid,  often  precipitate.  First  stage  is  very  short  and 
rather  painless. 

Colombo,  CEYLOisr.^ — Ovarian  uterine  tumors,  extra- 
uterine gestation,  and  pelvic  cellulitis  following  puerperal 
injuries  are  very  conunon.  The  native  method  of  ac- 
couchement is  purely  expectant  in  tj^e;  no  attenipt  is 
made  to  find  out  the  presentation;  no  antiseptics  are 
used  but  an  oil,  expressed  from  the  seeds  of  the  mayosa 
tree  and  said  to  i)ossess  antiseptic  projDerties,  which  is 
freely  applied  over  the  abdomen  and  is  also  taken  in- 
ternally. 

Shoka,  Formosa.^ — Ovarian  tumors,  cysts,  dermoids, 
and  polypi  fairly  common.  Displacements  and  prolapse 
of  the  uterus  very  conunon.    Ovaritis  and  pelvic  cellulitis. 


226  TROPICAL    SURGERY    A^B    DISEASES 

puerperal  or  gonorrheal,  and  endometritis  common. 
Puerperal  injuries  often  lead  to  sloughing,  cicatrization 
and  stenosis  of  the  vagina  and  to  vesicovaginal  and  recto- 
vaginal fistulas ;  fibroids  of  uterus  not  uncommon. 

Samoa. ^ — Chronic  pelvic  disease  among  the  native 
women  is  practically  unkno^^m.  Puerperal  sepsis,  how- 
ever, is  quite  common ;  five  cases  presented  for  treatment 
in  a  3^ear  in  which  about  two  hundred  births  were  re- 
corded. Gonorrhea  is  almost  unknown.  The  few  cases 
which  have  been  seen  can  nearly  all  be  traced  to  cases 
that  were  imported  about  two  years  ago.  When  pres- 
ent, the  disease  is  very  mild  in  its  course.  The  prevail- 
ing and  common  use  of  the  drink  called  "kava"  is  said 
by  some  to  lessen  the  liability  to  infection  from  this  dis- 
ease, but  the  infrequency  of  this  disease  is  probably  due 
to  isolation  from  lines  of  travel,  and  the  practical  absence 
of  a  prostitute  class. 

KoREA.^ — Genital  and  pelvic  disease  in  women  is  com- 
mon from  displacements  caused  by  unrepaired  lacera- 
tions, short  puerperium  and  general  enteroptosis,  of 
which  dilated  stomach  is  an  important  factor,  due  to 
constant  nursing  in  infancy,  irregular  eating  in  child- 
hood, and  gluttonous  eating  in  adult  life.  Complete  pro- 
lapse not  uncommon ;  native  treatment  is  to  burn  off  the 
presenting  part  with  strong  nitric  acid,  oil,  or  the  actual 
cautery.  The  result  is  functionally  good,  but  if  preg- 
nancy folloAvs,  then  the  case  is  serious.  The  treatment 
always  is  folloAved  by  cervical  stenosis  and  often  by  vag- 
inal stenosis.  Endometritis,  quite  conunon,  due  to  un- 
cleanly hygienic  habits,  sexual  indulgence  and  venereal 
insults.  Salpingitis  is  surprisingly  uncommon.  Fistula, 
vesicovaginal  and  rectovaginal  is  not  uncommon,  and 
often  is  extensive.  Lacerations,  very  common.  Ac- 
couchement :  Position,  sitting,  and  on  hands  and  knees, 
A\nien  labor  is  delayed,  it  is  believed  that  kneeling  on  a 
bear's  skin  will  cause  the  baby  to  come  quickh'.     Foil- 


■  aintswers  to  questionnaire  227 

well  speaks  of  the  custom  of  placing  the  beans  and  stalks 
of  the  castor  oil  plant  at  the  foot  of  the  patient.  Ap- 
parently the  danger  of  leaving  an  adherent  or  retained 
placenta  in  the  uterus  for  several  days  is  not  sufficiently 
recognized.  Accidents  and  nialpresentations  follow  ap- 
plication of  traction  on  the  presenting  part  and  the 
pushing  and  kneading  of  the  al^domen.  For  difficult 
labor  some  natives  use  hot  mud  poultice,  the  mud  taken 
from  a  rat  hole  and  applied  to  the  vagina,  or  a  fresh 
split  rooster  applied  to  the  vagina. 

Guam." — Ovarian  and  uterine  tumors  are  not  frequent. 
Three  cases  of  ovarian  cyst  were  operated  upon  and  tAvo 
of  fibroid  tumor  of  the  uterus.  Many  examinations  of 
the  pelvic  organs  Avere  made  and  these  were  the  only 
cases  found.  Three  cases  of  pyosalpinx  were  operated 
upon.  Lacerations  from  childbirth  Avere  common,  but 
seemed  to  cause  little  trouble.  Under  the  old  system  of 
midAvives,  puerperal  infections  Avere  common.  The 
method  of  accouchement  Avas  the  same  as  our  oAvn,  due, 
no  doubt,  to  the  instructions  given  b}^  tlie  physicians 
Avho  began  obstetric  work  among  the  natives  in  1900. 
The  Avomen  liaA^e  a  habit  of  tying  a  band  or  cord  around 
the  waist  above  the  uterus  for  some  time  before  labor 
for  the  XDurpose  of  keeping  doAvn  the  pain.  This  Avas  the 
only  peculiarity  seen. 

Genitourinary  Diseases  Among-  Men 

Rangoon,  Burma.^° — Venereal  affections  of  the  blad- 
der, penis,  and  testicles  are  very  common.  Hypertrophy 
of  prostate  is  rare,  but  has  been  seen.  The  numl)er  of 
men  liAdng  o\^er  the  age  of  sixty  years  is  small  in  Ran- 
goon. 

Agra,  India.^ — Genitourinary  diseases  among  men  are 
common  in  India  and  about  7  iDer  cent  of  our  admissions 
are  for  stricture,  perineal  abscess,  extraA^asation  of  urine, 
cystitis,  etc.     Enlargement  of  the  prostate  seems  from 


228  TROPICAL    SURGERY   AXD    DISEASES 

what  ^ve  see  here  to  be  common  among  old  men.  We 
never  see  the  cases  nntil  they  come  for  cystitis  and  reten- 
tion of  urine  and  are  usually  in  a  very  bad  condition. 
If  prostatectomy  is  performed  in  such  cases  as  these, 
they  hardly  ever  recover.  We  have  performed  quite  a 
number  of  prostatectomies,  but  in  more  favorable  cases 
and  about  50  per  cent  have  recovered  and  done  well. 

Hoxgkoxg"^^  axd  "Wexchow,^^  Chixa. — Genitourinary 
diseases  and  their  complications  are  common  in  men. 
Enlarged  prostate  is  not  common  chiefly  by  reason  of 
the  fact  that  Europeans  rarely  stay  out  long  enough  in 
the  East  and  this  complaint  has  not  been  found  among 
Chinese. 

Colombo,  Ceylox.'^ — Gonorrhea  is  fairly  common;  a 
large  proportion  of  these  cases  suffer  later  on  from  stric- 
ture. Hypertrophy  of  prostate  has  been  observed  in  a 
large  number  of  cases,  but  only  a  few  submit  to  operative 
treatment. 

Shoka,  Formosa,^ — Genitourinary  diseases  are  exceed- 
ingly common ;  e.  g.,  chancres,  buboes,  gonorrhea,  venereal 
condylomata  and  warts,  stricture  of  the  urethra,  orchitis, 
spermatorrhea  and  impotence.  Have  not  seen-hyper- 
troxDhy  of  the  prostate  in  old  men. 

Guam.- — Xo  cases  of  genitourinary  disease  were  found 
on  the  island.  Gonorrhea  is  not  very  coimnon  among 
the  men  as  they  marry  cpiite  young.  It  is  becoming  more 
frequent,  however,  as  there  are  more  men  being  enlisted 
on  the  station  ship  which  goes  to  Japan  or  China  about 
twice  a  year.  Primary  syphilis  and  chancroid  were  not 
seen  at  all  and  no  primary  syiDhilis  exists  on  the  island. 
I  believe  that  there  is  a  certain  immunity  to  the  disease 
OA^dng  to  the  hereditary  syphilis  (gangosa)  now  on  the 
island.  Only  two  cases  of  hypertrophy  of  the  prostate 
were  seen.  One  of  these  was  in  as  pure-blooded  a  Cha- 
morro  as  there  was  on  the  island. 

Samoa/ — Hyx)ertrophy  of  the  prostate  was  observed 


ANSWP:RS   to   QUESTIOXISrAIRE  229 

in  an  American  negro  resident  here,  but  no  case  has  been 
found  in  the  native  though  its  clinical  symptoms  often 
have  been  sought.  Rectal  digital  examinations  have  not 
been  made  in  a  series  of  cases. 

KoEEA.^ — Genitourinary  diseases  are  not  materially 
different  from  other  countries ;  bubo,  not  very  common ; 
stricture,  common;  urethritis,  nonspecific,  in  which  no 
gonococci  are  found.  Senile  prostate  rare.  No  one 
seems  to  have  made  any  special  search  for  the  condition 
and  cases  to  which  attention  was  called  b}^  s^anptoms 
were  rare  indeed.  Hypertrophy  from  gonorrheal  infec- 
tions is  common  enough. 

Appendicitis:  Rule  for  and  Method  of  Operating-;  Treat- 
ment of  General  Peritonitis 

RANGOoiir,  BuRMA.^° — Appendicitis  occurs  frequently. 
Operation  in  acute  stage  is  performed  at  the  earliest 
opportunity.  Results  are  excellent.  For  general  peri- 
tonitis following  perforation,  the  Fowler-Murphy  treat- 
ment with  free  abdominal  drainage  is  carried  out.  The 
results  have  been  very  gratifying. 

Agea^  Ixdia.^ — Ai^ioendicitis  is  not  connnon  among  na- 
tives of  India.  The  cases  we  see  are  almost  always  in 
the  European  hosj)ital,  we  always  operate  at  favorable 
periods  of  quiescence  and  the  results  are  very  satisfac- 
tory indeed. 

SoocHOw,  Chiista.^ — I  presume  that  I  have  seen  as 
many  as  ten  cases,  but  they  refuse  operation.  I  consider 
it  much  more  rare  than  in  the  United  States. 

Piis^G  Yi2^,  Chixa.^^ — Appendicitis  unknoA'STi. 

Wei^chow,  Chixa.^' — Appendicitis  ver}^  rare.  Have 
only  seen  one  or  two  cases  in  Chinese  which  I  have  diag- 
nosed as  appendicitis.  Chronic  abdominal  abscesses 
generally  discharge  worms,  making  the  diagnosis  of  the 
original    trouble  difficult. 

Shoka,  Formosa.® — Generally  see  appendicitis  at  the 


230  TROPICAL    SURGERY   AXD    DISEASES 

abscess  stage,  Avhen  tlie  treatment  consists  of  making  a 

hole  and  pntting  in  a  drainage  tube.    These  cases  do  well. 

Samoa.^ — Ap]3endieitis  is  quite  rare.     Only  one  case 

has  been  found  in  1000  surgical  conditions  operated  upon. 

Gastric  Symptoms  Caused  by  Gallstones,  Ulcer,  Appendi- 
citis and  Cancer 

Rangoon,  Bur:ma." — Several  cases  of  gastric  sym]D- 
toms  due  to  gallstones  have  been  met  with.  Gastric  and 
duodenal  ulcers  are  on  the  whole  rare,  but  occur  from 
time  to  time.  Cancer  of  stomach  is  not  of  frecjuent  oc- 
currence. Gastric  s^anptoms  due  to  appendicitis  have 
only  rarely  been  noted. 

Agra,  India.^ — Gallstone  disease,  gastric,  and  duodenal 
ulcer  and  appendicitis  are  not  common  among  the  na- 
tives in  this  part. '  They  are  rarely  seen  in  our  hospitals 
except  a  few  cases  in  women. 

Hongkong." — Gallstones  and  biliary  sand  are  very 
common.  Duodenal  ulcer  is  not  uncommon :  appendicitis 
is  very  common ;  cancer  of  the  bowel  not  common. 

Shoka,  Formosa.^ — Gastric  s^anptoms  common,  due  to 
too  much  food.  Operated  on  a  few  cases  of  gallstones 
and  several  cases  of  pyloric  stenosis  due  to  cicatrization. 
Appendicitis  is  generally  seen  at  the  abscess  stage. 

Guam.^ — Appendicitis  from  ordinary  causes  is  very 
rare.  There  were  only  four  cases  in  the  native  popula- 
tion during  two  years  stay  in  Guam.  All  persons  dying 
ill  Agana  and  immediate  vicinity  in  Avhich  the  cause  of 
death  had  not  been  accurately  determined  Avere  subjects 
of  postmortem  examination.  No  cases  Avere  found.  The 
population  of  the  area  Avas  about  8000.  The  cases  of  ap- 
pendicitis that  occurred  Avere  all  seen  rather  late  Avith 
one  exception  and  all  recovered  after  operation;  the 
course  of  the  disease  being  about  as  it  Avould  in  our  0A^^l 
people.  No  cases  of  gallstones.  There  Avere  no  cases  of 
fi'astric  or  duodenal  ulcer. 


ANSWERS    TO    QUESTIONiS^AHlE  231 

Samoa/ — Gastric  symptoms  due  to  indiscretion  in  diet 
are  not  unknown,  but  are  rare. 

KoREA.° — Gastric  symptoms  are  very  common;  many 
times  they  are  hard  to  distinguish  from  general  intes- 
tinal symptoms,  and  those  from  actual  disease  are  often 
lost  sight  of  or  at  least  cojifused  with  those  resulting 
from  adhesions  after  "needling."  This  makes  the  diag- 
nosis of  reflex  gastric  symptoms  doubly  hard.  Cancer 
has  been  definitely  located  in  a  number  of  cases.  Gall- 
stones have  been  suspected  in  a  few  cases,  but  their  ex- 
istence has  not  been  proved :  several  undoubted  gallstone 
cases  have  been  observed  in  fat  Avomen  in  most  of  whom 
jaundice  was  present.  Catarrhal  jaundice  without  pain 
or  other  evidence  of  complication  is  quite  common.  Di- 
lated stomach  and  associated  gastritis  are  prolific  causes 
of  distress  and  lead  to  the  oft-repeated  statement  that 
the  "food  doesn't  go  down  well." 

Dr.  H.  C.  Clark  (1914)  critically  examinmed  several 
hundred  native  laborers  of  the  Canal  Zone  in  regard  to 
reflex  gastric  disturbance  and  concluded  that  reflex  gas- 
tric symptoms  due  to  causes  from  the  gastro-duodeno- 
hepatico-pancreatic  system  awere  not  uncommon. 

Leprosy:  Leper  Colonies  and  Segregation;  Surgery  for 

Leprosy 

Rangooist,  Burma.^"- — Leprosy  is  common  and  Major 
Rost,  I.M.S.,  has  reported  successful  cases  of  injection 
by  his  vaccine.  The  cases  are  segregated  in  asylums  un- 
der medical  supervision.    No  leper  colonies. 

Agra,  India.^ — Leprosy  is  uncommon  in  this  part  of 
India.  All  the  cases  are  so  far  as  possible  segregated 
into  leper  asylums.  The  asylum  is  visited  by  health  of- 
ficers periodically. 

SoocHOw,^  PiifG  YiiiT^-  AjStd  Wexchow,^"  Chixa. — Lep- 
rosy of  the  anesthetic  type  is  in  this  region  though  not 


232  TROPICAL   SURGERY   AND   DISEASES 

abundant.  The  ''lion  face"  is  common.  There  is  no 
segregation.    The  people  have  slight  fear  of  it. 

Johannesburg,  Africa.^* — Leprosy  very  common  among 
many  South  African  tribes. 

Shoka,  Formosa.^ — Leprosy  fairly  common.  Have  tried 
nastin  in  vain.    Not  segregated. 

GrUAM.- — There  are  twenty-five  cases  on  the  island. 
Salvarsan  was  being  tried  in  the  treatment  of  the  disease, 
but  no  improvement  was  noted  in  any  patient.  Segrega- 
tion has  been  practiced  since  1902  and  there  was  some 
attempt  at  segregation  by  the  Spaniards.  The  disease 
does  not  seem  to  be  increasing  and  the  type  does  not  seem 
to  be  very  virulent. 

Samoa.^ — Leprosy  has  not  been  observed  in  American 
Samoa;  however,  a  small  colony  of  lepers  is  present  in 
German  Samoa. 

KoREA.^ — Leprosy  is  found  only  in  the  southern  half 
of  Korea.  Li  Seoul  the  average  is  one  case  a  month  and 
they  all  came  from  farther  south.  Not  segregated. 
There  exists  only  one  asylum  for  their  care. 

Yaws 

GuAM.^ — Fairly  common,  but  did  not  seem  so  much 
so  as  it  was  at  first  and  the  disease  is  certainly  not  so 
frequent  as  it  is  in  Samoa.  The  lesions  are  not  so 
numerous  or  "wet"  as  they  are  there.  Salvarsan  had 
not  been  tried. 

Samoa.^ — Every  Samoan  child  contracts  yaws,  as  a 
rule  about  the  age  of  three  to  five  years.  The  mother 
is  willing  to  expose  her  child  to  the  infection  because  she 
believes  it  is  better  for  the  child  to  have  it  in  early  life. 
Before  the  use  of  "606"  the  open  lesions  persisted  from. 
six  months  to  a  year  or  more  in  spite  of  treatment  mth 
potassium  iodide.  Since  the  use  of  "606"  the  open 
lesions  are  healed  in  a  week  or  ten  days.  Too  few  cases 
have  been  treated  in  this  manner,  to  date,  to  give  even 


ANSWERS    TO    QUESTIONNAIRE  233 

an  index  as  to  the  permanency  of  this  method  of  treat- 
ment. 

KoREA.^ — Yaws  not  observed. 

Tropical  Ulcers  and  Granulomas  of  Skin 

Kangoon,  Burm:a.^°— Tropical  nlcers  of  the  phagedenic 
type  have  been  snccessfully  treated  by  peroxide  of  hy- 
drogen. 

Johannesburg,  Africa.^'* — Ulcers  of  various  kinds 
prevalent  on  the  legs,  especially  among  mine  boys  work- 
ing under  ground. 

Wenchow,  China." — Tropical  ulcers  and  granulomas 
of  skin  common. 

KoREA.^ — Tropical  ulcers  not  found. 

Samoa.^ — A  common  form  of  nicer  as  a  rule  affects 
the  legs,  varies  in  size  from  the  area  of  the  palm  of  the 
hand  to  an  ulcer  involving  one-fourth  of  the  surface  of 
the  lower  leg;  commonly  seen  on  the  calf  instead  of  on 
the  anterior  tibial  region.  Other  sites  are  the  outer  lat- 
eral-tibial  and  flexor  aspects  of  forearm,  generally  more 
than  one  and  seldom  more  than  four.  These  ulcers  dis- 
charge a  stinking,  watery  fluid,  small  in  amount,  and  have 
a  yellowish  granulomatous  base  flush  with  the  epidermis 
which  can  be  easil}^  curetted  to  a  depth  of  one-fourth 
of  an  inch,  when  an  oozing,  bright  red,  clear  base  can  lie 
obtained  with  a  sharply  limited  ragged  skin  edge.  Cu- 
rettage followed  by  large  doses  of  potassium  iodide  and 
combined  with  surgical  cleanliness  have  resulted  in  a 
healing  ulcer  in  most  cases.  When  healed  a  thin,  broad, 
parchment-like  epidermal  scar  is  left,  not  unlike  the  scar 
of  syphilitic  ulceration.  It  is  believed  that  these  ulcers 
are  a  late  manifestation  of  the  ''^^aws"  though  the  be- 
lief has  not  been  backed  up,  as  yet,  by  an}^  specific  tests 
such  as  the  Noguchi  or  Wassermann.  Of  late  salvarsan 
has  been  used  in  a  few  cases  in  addition  to  the  other 


234  TROPICAL,    SURGERY    AND    DISEASES 

treatment  with  the  result  that  healing  has  apparently 
been  more  rapid. 

Guam.- — "Tropical  ulcers"  have  all  disappeared  with 
the  use  of  mercury  and  iodide  of  iDotash,  as  applied  to 
gangosa  (syphilis). 

Filariasis 

RANGOOi!^^  Burma." — Xo  experience.  Infections  are 
not  common  in  Burma.    - 

FiLARiA  IjST  the  PHILIPPINES. — Captain  Phalen  and 
Lieutenant  Nichols  of  the  United  States  Army  in  1908 
and  1909  made  about  7,400  blood  examinations  in  va- 
rious localities  to  get  an  idea  of  its  prevalence  and  dis- 
tribution and  found  the  disease  to  represent  2  per  cent  of 
infections  for  the  islands;  35  cases  had  eleiDhantoid  dis- 
ease. Protection  from  mosquitoes  is  preventive  but  this 
is  impracticable  for  a  native  population,  hence,  when- 
ever a  case  is  discovered,  among  the  native  employees, 
it  should  be  discharged  at  once  as  the  Culex  fatigans 
AVied.,  which  transmits  the  disease  is  onini|)resent. 

SoocHOw,^  HoNGKONG,^^  China. — Filaria  nocturna  has 
been  found  in  a  feAV  cases,  two  of  elephantiasis  and 
one  in  a  severe  case  of  cMduria.  Four  other  cases  of 
elephantiasis  have  been  examined  and  the  filaria  not 
found. 

Johannesburg,  Africa.^* — Filaria  nocturna  present  in 
some  areas. 

Shoka,  Formosa.® — Have  seen  a  few  cases  of  filaria 
nocturna.     Generally  associated  Avith  orchitis. 

Samoa.^ — Filariasis.  Salvarsan  tried  in  ten  cases 
without  benefit.  Complications :  localized  elephantoid 
swellings  treated  successfully  b}^  surgical  removal;  dif- 
fuse elephantoid  swellings  not  treated  with  success  sur- 
gically. 

Korea.® — Filariasis  not  found. 


ANSWERS    TO    QUESTIOXXAIKE  235 

Guam' — Tliirteen  cases  have  been  found.  No  symp- 
toms, no  treatment,  no  hematofhylnria. 

Ainhum  and  Goundou 

Manila." — The  board  has  seen  one  case  of  ainhum  in 
the  person  of  a  Jamaica  negro;  not  seen  in  Buema^"  or 
Formosa^  but  in  Johaxxesburg/*  Africa,^  the  disease  is 
fairly  common.     Goundou  not  diagnosed. 

Samoa^  Korea,  axd  Guam.- — Ainlnim  and  Goundou  not 
seen. 

Tumors:     Benign  and  Malignant 

Samoa.^ — Tumors,  libromas,  and  lipomas  most  often 
seen;  malignant  tumors  rare. 

Kokea.^ — Keloid  of  moderate  degree  quite  common; 
lipomas,  frequently  seen;  osteomas,  few;  angioma  and 
uterine  fibroids  few  cases;  papilloma,  common. 

Guam.- — LiiDomas  and  a  feAv  sebaceous  cysts  only  were 
seen.    Any  part  of  the  body  seemed  likely  to  1)e  the  site. 

Urinary  Calculi 

Rangoon,  Burma." — Urinary  calculi  are  very  much 
less  frequent  than  in  India.  Litholapaxy  is  the  selected 
operation  for  stone  in  the  bladder.  Eesults  only  mod- 
erately good,  chiefly  owing  to  want  of  experience. 

Agra,  India.' — Calculi  in  the  bladder  are  common  in 
India,  especially  in  children,  and  are  mostly  composed 
of  either  uric  acid  or  oxalates.  The  chief  operation  is 
litholapaxy  in  about  90  per  cent  of  the  cases.  The  re- 
sults are  very  successful,  hardly  any  cases  are  lost.  If 
litholapaxy  can  not  be  performed  because  the  stone  is 
too  large  or  the  urethra  too  small  for  the  passage  of 
instruments,  then  suprapubic  cystotomy  is  performed; 
and  the  bladder  drained. 

Hongkoxg,^^  Soochow,^  China,  and  Formosa. — Gravel 
more  common  than  stone  in  Europeans;  bladder  stone 
common  in  Chinese;  kidney  stone  not  diagnosed. 


236  TEOPICAL    SUEGERY   A:N'D    DISEASES 

Samoa/ — Urinary  calculi  of  bladder  and  kidney  not 
observed  clinically.    Antopsies  difficult  to  obtain. 

KoEEA.^ — Urinary  calculi  of  bladder  and  kidney ;  all  re- 
ports indicate  that  these  conditions  are  rare.  T\Tiether 
there  is  any  connection  with  the  water  supply  or  not, 
it  might  be  noted  that  the  geology  of  Korea  is  essen- 
tially granite  and  that  limestone  and  marl^le  occur  but 
in  very  limited  quantities. 

GuAM.^ — Urinary  or  renal  calculi  not  seen. 

Hodgkin's  Disease 

Eangoox,  Buema,"  Agea,  Ixdia,"  Soochow,  Chiista.^ — 
Hodgkin's  disease  very  rare,  only  one  case  has  been  def- 
initely diagnosed;  the  patient  was  a  European;  a  few 
cases  in  Hongkong,  and  in  Ping  Yin/-  China ;  in  Africa^'* 
prevalent  among  natives. 

Samoa/ — Hodgkin's  disease  not  seen,  though  enlarge- 
ments of  glands  are  connnon  from  other  causes. 

KoEEA.^ — Hodgkin's  disease  not  seen. 

GuAM.^ — No  cases  seen. 

Diabetes 

Rangoon,  Buema.^° — Diabetes  connnon  among  natives 
of  India.  Eare  among  Burmans.  Treatment  is  difficult 
because  natives  of  India  will  not  diet  themselves.  Gan- 
grene is  not  very  prevalent. 

Agea,  Iistdia."- — Diabetes  is  very  common  in  India,  espe- 
cially among  the  better  classes.  It  occurs  chiefly  among 
the  native  Hindus.  Gangrene  is  rare  among  diabetics, 
but  carbuncle  is  very  common  in  these  cases  and  is  fre- 
quently seen  in  the  hospitals. 

HoisTGKOxG.^^ — Glycosuria  common  in  Chinese ;  true  dia- 
betes not  so  common;  treatment,  high  frequency  auto- 
condensation  will  cure  glycosuria,  but  not  true  diabetes. 
It  is  infrecpient  in  Foemosa^  and  Weistchow,^^  and  in 
Afeica^*  diabetes  is  not  found.    Samoa.^ — Diabetes  seen 


ANSWERS    TO    QUESTIONNAIRE  237 

onty  in  one  instance  and  in  a  European.    Koeea.° — Dia- 
betes rare.    Guam.- — Xot  seen. 

Paralysis  Agitans 

Agra,  India,^  Bue,ma^°  and  Africa.^* — Paralysis  agitans 
is  rare  among  the  natives. 

Samoa,  Guam,  Korea. — Xo  eases  observed. 

Infantile  Paralysis 

•WENCH0^^',  Ping  Yin,  and  Formosa. — Infantile  jDaraly- 
sis  is  common. 

Korea.^ — Infantile  paralysis  cases  seen  long  after  acnte 
sj^nptoms  had  passed. 

Samoa.^ — Not  observed,  neither  acnte  nor  terminal  ef- 
fects. 

Guam.- — No  new  cases.  There  had  evidentl}^  been  an 
epidemic  some  eight  years  ago  as  several  yonng  people 
had  the  resulting  paralysis;  these  cases  were  fonnd  to 
have  had  the  disease  about  the  same  time. 

Hernia 

Rangoon,  Buema,^°  Agra,  India.' — Hernia  is  of  moder- 
ate frequency  among  the  working  classes.  The  cause 
is  probably  due  to  muscular  exertion.  It  is  not  so  com- 
mon as  among  Europeans  and  one  reason  may  be  the 
position  a  native  assumes  in  the  act  of  defecation;  i.e., 
sitting  on  his  feet  with  the  inguinal  rings  well  protected 
by  the  thighs ;  nor  do  natives  work  as  hard  as  Europeans. 
Is  much  more  frequent  among  the  hard  working  Chinese 
in  China,  also  in  Formosa  and  in  Africa.^'* 

Samoa.^ — Hernia  is  rarely  seen,  probably  because  they 
do  not  jDresent  with  it ;  tAvo  cases  of  strangulated  variety 
seen  in  five  hundred  operations,  one  inguinal,  one  fem- 
oral. 

Guam.- — Hernia  is  quite  frequent  in  men,  and  strangu- 


238  TROPICAL  SURGERY  AXD  DISEASES 

lation  was  common.  There  were  no  cases  seen  in  the  fe- 
male. All  cases  Avere  oblique  inguinal  and  aside  from 
congenital  defects,  the  only  cause  seemed  to  be  the  gen- 
eral anemic  condition  resulting  from  hookworms  and  the 
heavy  labor  incident  to  obtaining  saw  logs. 

Korea. ^ — Hernia  is  stated  by  every  one  to  be  quite 
common  in  children  and  adults ;  most  cases  are  operated, 
few  trusses  being  used. 


^& 


Tropical  Abscess 

Samoa.^- — Abscess  is  the  most  frequent  surgical  condi- 
tion met  with.  These  abscesses  are  deep-seated,  as  rule, 
close  to  or  surrounding  a  large  artery,  very  little  indura- 
tion, very  similar  to  the  abscesses  seen  in  low  grade  sep- 
ticemias ;  generally  single ;  common  sites ;  brachial  artery 
just  above  elbow,  femoral  artery  Scarpa's  triangle,  iliac 
artery  pointing  at  anterior  superior  spine  of  the  ilium; 
little  or  no  constitutional  reaction;  common  organism  a 
staphylococcus  of  low  virulence ;  ra]3id  recovery  by  drain- 
age through  small  opening. 

KoREA^  ai^d  Guam.^ — Tropical  abscesses  not  seen. 

Congenital  Defects 

RAiiTGOOi;^,  Burma." — Congenital  defects  are  on  the 
whole  somewhat  rare,  except  imperforate  anus  which  is 
not  uncommon. 

Agra,  Ixdia,"  axd  Formosa.^ — All  the  congenital  defects 
are  fairly  common  except  squint.  In  Ixdia  accessory 
fingers  are  very  commonly  seen,  but  natives  will  never 
have  the  accessor}'  finger  amputated  as  it  is  considered 
a  sign  of  bad  luck. 

Guam.- — The  natives  of  Guam  seem  remarkably  free 
from  congenital  defects ;  very  few  cases  of  talipes,  squint, 
harelip,  and  but  one  of  cleft  palate  and  clubbed  feet  and 
hands. 

Samoa.^ — Harelij),  cleft  iDalate,  club-foot,  one  of  each 


ANSWERS    TO    QUESTIOXXAIRE  239 

ease  has  been  seen  in  last  six  thousand  eases  treated; 
squint  seems  to  be  rare. 

Korea. ° — Squint  not  unconnnon ;  treatment  was  not  de- 
sired. Harelip,  quite  common  and  it  is  the  experience 
of  everyone  that  onee  you  begin  to  treat  these  eases  your 
"fame"  immediately  spreads  and  patients  eome  until 
the  condition  seems  more  common  than  it  really  is.  All 
stages  of  the  deformity  are  found  to  exist  from  a  mere 
notch  to  a  generally  ''open  countenance."  Cleft  palate, 
clubbed  feet  and  hands,  polydactylism,  imperforate  anus, 
hermaphroditism,  undescended  testicle,  imperforate  va- 
gina, exstroph}^  of  the  bladder,  hypospadias,  atresia  of 
the  vagina  and  absence  of  uterus,  one  ease  each. 

Varicose  Veins 

Raxgoox,  Burma;"  Agra,  Ixdia;^  Philippines. — Vari- 
cose veins  seldom  require  operation.  Hydrocele  ex- 
tremely common  among  natives  of  India,  not  so  common 
among  Burmans  who  do  not  wear  tight  fitting  "loin" 
cloth ;  varicose  veins  are  common  among  the  coolie  class 
in  China. 

Samoa. ^ — Varicose  veins  observed  in  natives  but  once. 

Korea.® — Rather  uncommon. 

Guam. 2 — Xo  cases  of  sufficient  magnitude  to  attract  at- 
tention were  seen. 

Hemorrhoids  and  Fistula 

India,'  Burma,"  China  and  Formosa. — Hemorrhoids 
and  fistula  are  of  moderate  frequency.  More  frequent 
among  those  following  a  sedentary  occupation. 

Samoa. — Hemorrhoids  and  fistula  not  seen. 

KoREA.^ — Hemorrhoids :  Everyone  states  that  the  con- 
dition in  a  mild  form  is  quite  common  and  that  severe 
cases  are  not  often  seen.  The  continued  sitting  posture 
is  a  reason  advanced  for  the  presence  of  the  affection 
since  constipation  is  so  uncommon.    It  is  worthy  of  note 


240  TROPICAL    SURGERY   A^iTD    DISEASES 

that  altliougli  this  affection  of  the  rectal  blood  vessels 
is  less  common  than  in  America,  that  of  infection,  as 
represented  by  abscess  formation  and  tistula,  is  mnch 
more  prevalent.  Fistula :  All  agree  npon  the  frequency 
of  this  affection  in  mild  and  aggravated  forms.  Patients 
in  Kangkai  have  rei^eatedly  told  the  writer  that  pin- 
worms  cause  these  fistulas  and  that  their  exit  has  been 
frequently  seen.  The  treatment  by  repeated  needling 
and  lancing  of  the  anus  in  certain  cases  of  chronic  gas- 
troenteritis of  children  and  3"oung  adults  and  in  other 
abdominal  conditions,  with  as  yet  undifferentiated  symp- 
tomatolog}^,  on  the  assumx)tion  that  they  Avere  suffering 
from  "rectal  disease,"  probably  is  a  cause.  The  lack  of 
an}^  or  sufficient  cleansmg  after  defecation  in  a  large 
proportion  of  the  population  must  be  an  important  pre- 
disposing cause.  The  warm  floor  is  also  believed  to  have 
a  causal  influence.  Treatment:  Cut  and  scrape,  some 
use  bismuth  paste.  Two  hundred  cases  were  treated  with 
excellent  results  in  nearly  all  except  tuberculous  patients. 
Guam,- — Hemorrhoids  were  not  common,  a  few  ceases 
only  and  only  one  case  necessitating  a  Whitehead  opera- 
tion.   Fistula  rare. 

Actinomycosis,  Glanders,  Echinococcus 

Burma." — No  actinomycosis  as  an  indigenous  disease; 
a  few  cases  of  "Madura  foot"  are  seen,  but  they  were  al- 
ways imported  from  India.  Glanders  is  exceedingly  com- 
mon among  the  ponies  of  the  iDublic  conveyances  in  Ean- 
goon.  Cases  of  acute  glanders  in  man  were  met  mtli 
three  times  last  year,  but  they  are  probably  commoner 
than  is  supposed,  for  in  the  house  from  which  one  of 
last  year 'si  cases  came,  three  people  died  of  "abscesses" 
during  two  years.  Bacteriologic  examinations  are  not 
carried  out  save  among  the  comparatively  few  patients 
who  come  to  the  hospital.  There  is  a  disease  which  re- 
sembles glanders  very  closely  and  Avhicli  is  fairly  com- 


AXSWERS    TO    QUESTIOXXAIKE  241 

mon  among-  the  natives  of  Rangoon.  So  far  as  we  are 
aware  tliis  disease  lias  not  been  hitherto  described;  a 
full  description  of  this  disease  will  l)e  pnljlished  as  soon 
as  our  bacteriologic  work  has  been  confirmed.  Echino- 
coc-cus  infection  has  been  reported  among  the  natives  of 
Burma,  but  every  case  examined  in  the  laboratory  or  in 
the  mortuary  has  proved  to  be  a  mistaken  diagnosis. 

Agea,  Ixdia;^  Foemosa;  South  axd  AVest  Afeica. — Xo 
cases  of  these  diseases. 

Samoa.^ — Actinomycosis,  glanders,  and  echinococcus 
not  seen. 

KoEEA.'' — ^^Veir  rejoorts  one  bone  case  of  actinomycosis. 
No  cases  of  glanders  reported.  Dr.  Oh,  of  Kunsan, 
Korea,  in  a  personal  communication  stated  that  he  had 
had  one  liver  case  of  echinococcus.  Several  cases  of  an- 
thrax rei^orted. 

Tonsils  and  Adenoids  in  Children 

BuEMA,"  IxDiA,'  South  axd  West  Afeica." — Tonsils 
and  adenoids  are  not  so  common  among  native  children 
as  among  Europeans.  Xative  children  live  an  open  air 
and  free  life.  Xasopharyngeal  diseases  are  very  fre- 
quent in  Hoxgkoxg"  and  other  crowded  Chinese  cities. 
Xearly  every  child  one  examines  has  a  hypertrophied 
Luschka's  tonsil;  ptosterior  rhinoscopy  shows  hyioer- 
troj)hic  swelling  of  the  orifices  of  the  eustachian  tubes 
and  some  swelling  of  the  posterior  ends  of  the  inferior 
turbinate  bones.  All  Chinese  patients  have  some  post- 
nasal catarrh  accompanied  by  an  excessive  secretion  of 
mucus,  due  to  their  extremely  crowded  and  unhygienic 
mode  of  life ;  also  their  excessive  ingestion  of  farinaceous 
food  leads  to  an  increased  production  of  mucus  not  only 
in  the  alimentary  canal,  but  from  all  the  mucous  tracts. 

Samoa.^ — Adenoids  in  pure-blooded  natives  sought  and 
not  found.  Adenoids  common  in  young  half-castes,  white 
and  Samoan. 


242  TEOPICAL    SURGERY    AXD    DISEASES 

Korea.® — Adenoids  in  children.  This  subject  seems 
not  to  have  attracted  the  attention  of  the  various  phy- 
sicians to  any  great  extent.  Mouth-hreathing  as  an  af- 
fection of  sufficient  importance  to  modify  the  facial  ex- 
pression is  at  least  not  common;  doubtless  many  of  the 
prevalent  "running  ears"  and  sore  throats  would  dis- 
appear if  one  could  remove  the  adenoids. 

Guam'^ — Adenoids  and  mouth-breathers,  very  rare. 

Infectious  Diseases  of  Children 

Burma." — Diphtheria  and  scarlatina  very  infrecpient. 
Mumps  common  among  natives  of  India  from  the  hill  dis- 
tricts and  less  common  among  natives  of  Burma  from  the 
hills.  Among  the  natives  of  Burma  who  live  in  the  plains, 
noma  is  very  rare. 

Manila.^'^ — Diiohtheria  a  few  years  ago  was  considered 
ver}^  rare  in  the  Philippines.  Whether  unrecognized  be- 
fore or  more  recently  introduced,  it  is  now  found  not  in- 
frecjuently.  In  one  case  virulent  bacilli  were  present  in 
the  throat  ninety  days  after  the  onset  of  the  disease  and 
disappeared  promptly  on  spraying  the  throat  with  a  cul- 
ture of  staphylococcus  pyogenes  aureus.  In  another  case 
in  which  were  found  virulent  bacilli,  after  twenty-one 
days  similar  prompt  disappearance  occurred  after  using 
the  staphylococci. 

Agra,  Ixdia.^ — Diphtheria  is  not  common,  but  it  is  seen 
occasionally  among  native  children ;  never  in  an  epidemic 
form.  Scarlatina  never  seen  among  European  children 
in  schools.  Measles  is  very  common  both  among  Euro- 
pean and  native  children.  Noma  never  seen  in  this  part 
of  India. 

HONGKOXG^^  AKD    ChIXESE    CiTIES'''  ^',    FoRMOSA,-    AXD  IX 

SouTH^*  AXD  AVest*^  Africa. — Scarlatina  is  practically  un- 
known. Cases  that  have  been  reported  have  been  of 
doubtful  diagnosis  or  have  been  imported.  Diphtheria 
is  not  common;  pseudodij)htheria  more  so  and  a  mem- 


ANSWERS    TO    QUESTIOXXATRE  243 

l)raiions  affection  of  the  tlii'oat  due  to  streptococcus  pyo- 
genes still  more  coiiiiiiou.  Postdiphtheritic  paralysis  is 
not  a  common  sequence.  MumjDS  is  very  common,  espe- 
cially among  the  Chinese.  Mucus  disease  is  an  exces- 
sively eonnnon  complaint  among  the  European  childi-en 
horn  or  resident  in  the  East,  due  in  the  main,  to  native 
servants  acting  without  maternal  supervision  and  over- 
feeding the  children  of  ahout  seven  years  of  age;  cer- 
tainly it  is  more  frequent  in  cliildi-en  of  this  age  than 
in  younger  children.  This  disease  is  very  amenable  to 
treatment,  a  rectified  diet  and  small  doses  of  arsenic 
and  occasionally  minute  doses  of  opium  to  control  the 
lienteric  diarrhea  which  is  very  prone  to  result  therefrom. 

Samoa, ^ — Diseases  of  children  occur  only  when  intro- 
duced from  other  islands.  Chicken-x)ox  has  been  endemic 
for  some  years.  An  epidemic  of  measles  occurred  during 
the  past  year  attacking  practically  every  person  under 
the  age  of  nineteen,  killing  about  8  per  cent.  Dysentery 
occurring  during  convalescence  was  the  cause  of  death. 

Korea." — Diphtheria  is  not  often  seen  by  the  for- 
eigners. It  is  increasing  in  frequency.  Perhaps  this  is 
apparent  only  because  of  a  more  widespread  use  of  the 
dispensar}'  by  the  common  people  for  the  treatment  of 
minor  affections.  It  is  possible  that  the  concentrated 
tobacco  smoke  of  the  Korean  house  operating  contin- 
uously day  and  night  may  decrease  the  frecpiency  of  in- 
fection; the  degree  of  contagiousness  is  very  evidently 
much  beloAv  that  found  in  America.  Scarlatina  reported 
as  having  been  seen  by  only  three  men  and  they  say  it  is 
rare.  Hirst  believes  it  is  increasing  in  frequency  some- 
what. Parotitis  is  uncommon  in  some  regions,  common 
in  others.  Every  doctor,  except  one,  reports  cases  of 
noma  and  most  speak  of  it  as  being  fairl}^  common.  All 
these  cases  were  fatal  except  one,  and  all  were  seen  sev- 
eral days  after  the  onset.  Most  of  the  cases  Avere  seen 
during  epidemics  of  measles.    One  case  of  diphtheria  was 


244  TEOPICAL  SURGERY  AND  DISEASES 

reported  in  which  antitoxin  was  used.  Mumps :  epidemic 
in  1910 ;  53  cases.  Measles  epidemic  in  1909.  Whooping- 
cough  eiDidemic,  59  cases.  Ophthahnia  is  common.  Many 
cases  of  syphilis  seen. 

Guam. ^— No  di]Dhtheria,  scarlet  fever,  mumps,  small- 
pox or  noma.  Had  about  fifty  cases  of  chicken-iDox  and  a 
good  many  cases  of  yaws;  epidemic  conjunctivitis  was 
common  in  the  late  part  of  1909  and  early  part  of  1910. 
There  also  is  a  conjunctivitis  more  common  in  children 
and  young  adults  though  by  no  means  uncommon  in 
adults,  which  resembles  trachoma  but  which  yielded  quite 
readil^T"  to  %  per  cent  zinc  sulphate  solution.  There  is 
a  disease  known  locall^^  as  ''guha"  and  which  has  been 
described  under  the  name  of  "epidemic  asthma,"  which 
is  more  prevalent  during  the  periods  of  greatest  rain- 
fall, Jul}^  to  October.  It  is  quite  fatal  in  young  children 
and  occurs  occasionally  in  adults.  There  is  a  fever  of 
moderate  severit}^,  no  glandular  involvement,  and  the 
postmortem  picture  resembles  a  capillary  bronchitis. 
Guha  has  not  been  seen  in  a  foreigner. 

Ludwig's  Angina 

Burma." — Ludwig's  angina  not  frequent. 
India,^  Formosa,®  West*'  and  South^*  Africa. — Lud- 
wig's angina  is  never  seen. 

Samoa.^ — Not  observed.     Korea. ^ — Rare. 

Elephantiasis 

Burma." — Elephantiasis  of  moderate  frequency.  Much 
less  so  than  in  Southern  India.  The  vast  majority  of 
cases  are  imported  from  India. 

Agra,  India.^ — Elei)hantiasis  is  not  found  in  these 
parts,  we  occasionally  see  a  case  that  has  come  from 
Lower  Bengal  or  the  South  of  India  where  it  is  common. 

Ping  Yin,  China.^- — Elephantiasis  rare ;  in  Wenchow, 
China,^'  is  common;  none  in  Formosa,®  but  in  South 


AXSWElt.S    TO    Qt'ESTIO^'XAIIlE  245 

Afeica,^*  elepliantiasis  very  common;  in  some  parts  of 
the  East  Coast,  also  in  some  localities  in  West  Afeica.'' 

Guam. — There  was  but  one  case  of  elepliantiasis  on  the 
island. 

Samoa."^ — Perhaps  one  in  every  hundred  adults  has 
some  form  of  elephantiasis :  legs  most  common ;  scrotum 
next,  penis  next,  breast  next,  arms  next.  ExiDerience 
here  seems  to  i)oint  to  the  truth  of  the  surgical  princi- 
ple, that  a  localized  elephantoid  swelling  which  is  com- 
pletely removed  by  surgery  is  not  liable  to  return,  but 
a  diffuse  elephantoid  swelling  attacked  and  partly  re- 
moved surgically,  will  probably  be  aggravated  by  the 
surgical  interference  and  in  a  year  or  two  become  of 
greater  size  that  it  would  have  become  if  no  operation 
had  been  performed.  The  native  believes  that  the  scar 
left  by  an  infected  wound  in  elephantoid  tissue  Avill  check 
the  growth  of  the  SAvellings  and  he  j)ractices  this  method 
of  treatment  Avith  some  show  of  success. 

Koeea'^  axd  Philippines. ^-^^ — Not  frequent. 

Skin  Diseases 

Burma. ^" — Yaws  common  in  the  Chindwiii  District  of 
Upper  Burma;  rare  elsewhere.  Skin  diseases  have  not 
been  investigated  with  any  thoroughness  at  this  hospital. 

IManila.^'^^A  member  of  the  United  States  Army 
Board  has  conducted  a  clinic  on  skin  disease  for  several 
years  in  the  Philippine  Cleneral  Hospital.  The  532  cases 
that  have  been  observed  and  treated  during  that  time 
are  tabulated  as  follows : 

Dermatomy coses. — Blastomycosis,  11,  2.07%  ;  tinea  cir- 
cinata,  171,  32.14%;  tinea  versicolor,  14,  2.63%;  tinea 
nigra,  2,  2.63%  ;  tinea  s^'cosis,  2,  .38%  ;  tinea  tonsurans,  1, 
.19%;  tinea  favus,  4,  .75%;  tinea  imbricata,  4,  .75%;  un- 
determined, 11,  2.97%. 

Infections,  Prohably  Bacterial. — Impetigo  simplex,  20, 
3.76% ;  acne  vulgaris,  14,  2.63%  ;  iin]3etigo  contagiosa,  10, 


246  TROPICAL    SURGERY    AXD    DISEASES 

1.88%;  dermatitis,  46,  8.65%;  dermatitis,  vesicular,  3, 
.56%  ;  dermatitis  papular,  8,  1.5%  ;  cellulitis,  1,  .19%  ;  in- 
fected Avound,  1,  .19% ;  furunculosis,  3,  .56% ;  folliculitis, 
pustular,  4,  .75%  ;  leprosy,  1,  .19%. 

Diseases  Due  to  Protozoa  and  Animal  Parasites. — 
Ground  itch,  1,  .19% ;  syphilis,  secondary,  10,  1.88% ; 
syphilis,  tertiary,  1,  .19% ;  mites,  unclassified,  3,  .56% ; 
scabies,  25,  4.7%  ;  yaws,  11,  2.07%. 

General  Skin  Diseases. — Pemphigus,  4,  .75% ;  pom- 
pholyx,  11,  2.07%;  psoriasis,  6,  1.13%;  herpes,  5,  .94%: 
herpes  zoster,  7,  1.32% ;  lichen,  1,  .19% ;  seborrhea,  3, 
.56% ;  dermatitis  venenata,  2,  .38% ;  gangrene,  moist,  11, 
.19%  ;  eczema  exfoliatum,  1,  3.2%  ;  eczema  sclerosum,  24, 
4.51%;  eczema  erythematosum,  3,  .56%;  eczema  papulo- 
sum,  3,  .56%  ;  urticaria,  1,  .19%  ;  vitiligo,  1,  .19% ;  pru- 
rigo, 3,  .56% ;  blisters,  1,  .19%  ;  alopecia  areata,  1,  .19% ; 
hyperkeratosis,  10,  1.88%;  undetermined,  46,  8.65%; 
grand  total,  532  cases. 

Blastomycosis  of  the  skin  has  been  studied  extensively 
by  the  Board.  (See  the  Philippine  Journal  of  Science, 
iii.  No.  5,  p.  395,  Section  B,  November,  1908.)  Blastomy- 
cosis of  the  lungs  has  also  been  found.  In  Chixa  ais^d 
Formosa®  skin  diseases  of  every  variety  exist. 

Samoa.^ — The  common  skin  diseases  are :  chromophy- 
tosis,  trichophytosis,  a  pustular  disease  of  extremities, 
a  scabies-like  disease. 

KoREA.^ — Psoriasis,  fairly  common,  except  in  the  north, 
where  a  dozen  a  year  out  of  two  thousand  skin  cases 
were  seen.  Scabies,  very  prevalent.  Lacquer  derma- 
titis and  poisoning,  occasional,  sometimes  fatal,  espe- 
cially among  hat  makers  and  occasionally  the  Avearers. 
Ichthyosis,  fairly  common.  Eczema  and  dermatitis,  uni- 
A^ersal.  Acne  vulgaris,  not  very  common,  chiefly  among 
better  classes.  Acne  rubra,  rare.  Acne  indurata,  few 
cases.  Alopecia,  rare.  Dermatitis  calorica,  common. 
Dermatitis   exfoliativa   or  iDityriasis   rubra,   tAvo   cases, 


ANSWERS    TO    QUESTIOXXAlllE  247 

both  died.  Dermatitis  medicamentosa,  two  cases  due  to 
iodoform;  one  in  Japanese.  Dermatitis  venenata,  occa- 
sionally. Erysipelas,  few  cases  each  year.  Herpes, 
rare.  Hyperidrosis,  few  cases.  Leucoderma,  common, 
ne^ois,  feAv  cases.  Pediculosis,  common.  Urticaria,  feAV 
cases. 

Guam.- — Skin  diseases  are  not  eonnnon  in  Guam; 
"ground  itch"  is  frequentl}^  seen,  and  tinea  eircinata  is 
fairly  common.  Ichthyosis  Avas  more  common  than  in 
any  other  tropical  country  in  Avhich  I  have  had  duty. 

Trichophyton  Skin  Infections — "Prickly  Heat" 

Agea/'^  Raxgoox"'  axd  Formosa,^  Ixdta. — Very  common 
indeed  among  all  natives  of  the  lower  classes.  Treat- 
ment consists  of  mercurial  and  chrysophanic  ointments, 
iodine,  and  x-rays.  Prickly  heat,  although  often  extensive 
and  troublesome  in  hot  weather  and  rainy  season,  is  not  a 
disability.  It  is  treated  with  lotio  hydrarg.  perchlor.  (1 
:1000)  and  drying  powders  of  boric  acid,  oxide  of  zinc, 
and  starch. 

KoREA.^ — Trichophyton  skin  infections  are  found,  ring- 
worms of  the  general  surface,  genitocrural  region  and 
of  the  scalp  are  seen  occasionally.  Treatment  consists 
in  plenty  of  green  soap  and  water  washings,  iodine,  and 
sulphur  ointment. 

Samoa. ^ — Trichophyton  infections  are  very  common. 
It  is  difficult  to  find  a  native  without  one  of  its  forms. 
Treatment  used  is  tincture  of  iodine  locally  with  excel- 
lent results.  Only  one  case  of  tinea  eircinata  has  been 
seen,  and  that  in  a  man  Avho  belonged  to  an  island 
(Tokelau)  where  the  disease  is  endemic.  Prickly  heat  is 
far  more  severe  than  the  type  seen  in  more  temperate 
regions.  No  satisfactory  treatment  has  l)een  evolved. 
Sea  bathing  seems  to  aggravate  the  condition  in  Samoa 
rather  than  relieve  it,  j)robably  because  of  the  numerous 


248  TEOPICAL    SURGERY   AND    DISEASES 

forms  of  phosphorescent  animalcules  in  the  sea  water. 
Treatment  most  satisfactory  from  a  palliative  stand- 
IDoint  is  a  wash  of  aluminum  acetate  with  one  per  cent 
carbolic  acicl. 

Guam.- — Tinea  circinata  is  fairly  common,  though  not 
so  much  so  as  it  was  in  the  Philippines  in  1900-1902 ; 
treatment,  15  per  cent  salicylic  acid  in  alcohol.  Heat 
rashes  were  rare  and  caused  no  disability. 

Furunculosis 

Agra,^  Eangoon,"  India. — Furunculosis  is  seen  in  the 
hot  weather  and  rainy  season,  and  it  is  fairl}''  common 
especially  among  Europeans.  Our  procedure  is  to  take 
a  culture  from  an  unopened  boil,  prepare  a  vaccine,  and 
give  regular  doses.  The  cases  alwa^^^s  do  well  under  vac- 
cine treatment;  staphylococcus  albus  is  generally  found. 

Hongkong,"  Ping  Yin^-  and  Formosa,^  China. — Furun- 
culosis very  common  in  the  hot  months,  best  treated 
mth  autogenous  vaccines ;  no  failures  yet  from  this 
method  of  treatment;  tincture  iodine  applied  in  out 
cases. 

Samoa.^ — Furunculosis  is  rarel}^  seen  in  the  native ;  is 
frequently  seen  in  the  white  race,  about  the  same  as  in 
temperate  climate.  Best  treatment,  autogenous  vaccina- 
tion. 

Korea. ^ — Furunculosis  is  seen  eveiywhere.  The  cus- 
tom of  pasting  little  pieces  of  oiled  paper  over  any  sore 
prevents  the  healing  and  creates  a  tendency  to  spread. 
Cases  are  treated  by  cleansing  incision  where  necessary, 
and  a  70  per  cent  alcohol  dressing  has  proved  effective. 

Guam.- — Furunculosis  is  common  among  Americans. 
Treatment:  incision,  carbolic  acid,  alcohol  applications, 
and  the  use  of  Bier's  cups.  A  few  cases  necessitated  the 
use  of  vaccines  and  the  results  were  good.  The  condi- 
tion did  not  seem  at  all  common  among  the  natives. 


ANSWERS    TO    QUESTlONNAMtE  249 

Pemphigus  Contagiosum 

Manila.^' — Tho  treatment  of  pemphigus  contagiosum 
lias  been  very  simple.  We  have  had  very  good  success 
using  equal  parts  of  pure  camphor  and  carbolic  acid. 
The  skin  of  the  bleb  is  torn  away  and  the  denuded  area 
well  swabbed  with  this  mixture.  If  all  vesicles  are  so 
treated  before  they  rupture  and  spread  the  infection,  the 
disease  may  be  cured  in  a  few  days.  Tincture  of  iodine 
is  also  very  efficient  used  in  this  way. 

Hongkong." — Pemphigus  contagiosum  very  common ; 
treatment  by  biniodide  of  mercury  1 :2,000  and  a  dusting 
powder  of  equal  parts  of  talc,  boric,  and  salicylic  acids. 

Samoa.^ — Pemphigus  contagiosum  not  present. 

Korea. ^ — One  case  in  a  girl.  Treatment ;  wash  of  lime- 
Avater  and  dusting  powder  of  boric  acid  and  starch. 

Guam.^ — A  few  cases  among  children.  Treatment: 
cleanliness  and  Fowler's  solution. 

Lesions  of  Lower  Extremities  in  Barefoot  Natives 

.  Rangoon,  Burma." — A  curious  melanotic  sarcoma  of 
the  heel  has  been  seen  upon  one  or  two  occasions. 

Agra,  India.^ — Few  cases  of  any  trouble  of  the  feet  in 
natives.  Occasionally  they  get  fissures  from  the  hard 
skin.  Cancer  of  the  skin  of  the  feet  among  natives  has 
not  been  observed. 

Hongkong." — A  pemphigoid  eczema  occurs  on  the 
skin  of  the  feet  which  is  of  an  exceedingly  contagious  na- 
ture. It  is  characterized  by,  at  the  first,  intense  itching, 
generally  between  the  toes,  tlieii  on  the  soles  of  the  feet; 
later,  a  vesicle  forms,  the  contents  of  which  spread  the 
affection  to  other  parts  of  the  body;  the  final  condition 
being  a  purulent  one.    No  organism  discovered, 

Formosa,^  Ping  Yin,^-  and  Wenchow,^'^  China. — Car- 
cinoma has  been  observed  on  the  sole  of  the  foot  fol- 
lowing cut,  plus  infection  and  Chinese  treatment  by  ir- 
ritating plasters. 


250  TROPICAL    SURGERY    AXD    DISEASES 

Korea.'' — Lesions  of  skin  of  lower  extremities  not 
found. 

Guam." — Skin  trouJjles  of  the  loAver  extremities  con- 
fined largely  to  the  ''ground  itch"  jDrobably  caused  by 
the  hookworm. 

Samoa.^ — Lesions  of  skin  of  lower  extremities  in  bare- 
foot natives  exceedingly  common.  There  are  three 
t^^pes :  First,  in  young  children,  multiple  small  punched- 
out  sores  called  "poi,"  look  not  unlike  pustular  eczema; 
begin  as  a  successive  crop  of  pustules  beneath  a  super- 
ficial layer  of  epidermis,  commonly  on  soles  of  feet, 
palms  of  hands,  legs  up  to  knees,  rarely  on  arms  and 
body,  and  are  chronic ;  weeks  to  recover ;  little  or  no  con- 
stitutional reaction;  recovery  under  cleanliness  and  ap- 
plication of  mild  parasiticides  such  as  balsam  of  Peru; 
commonly  found  to  be  a  precursor  of  yaws,  though  in 
all  probability  an  independent  condition.  Second  type: 
in  adults  as  a  rule;  scabies-like  involvement  of  skin 
mainly  on  the  legs  and  bodies ;  no  parasite  demonstrated ; 
seems  to  affect  whole  families ;  slow  chronic  course  ag- 
gravated by  salt-water  bathing ;  thickening  of  epidermis, 
dry,  scaly  itching  lesions  believed  to  be  due  to  a  parasite 
living  in  the  sleeping-mats.  Third  type:  large  ulcers  in 
adults. 

GANGOSA 

Chixa,^-'  ^^  KoREA,°  Formosa,^  Burma,"  Samoa/  axd 
Africa.'"  " — Gangosa  was  not  observed. 

Guam.- — AVe  are  satisfied  that  the  disease  is  inherited 
syphilis  transmitted  for  several  generations,  the  exact 
date  of  its  introduction  into  the  island  being  unkno^^ii. 
Clinically  the  lesions  are  those  of  syphilis.  AVasser- 
mann,  positive  in  about  85  per  cent  of  the  cases  tested, 
and  also  present  in  practically  all  of  the  cases  in  which 
the  blood  relatives  (brothers  and  sisters)  were  tested. 
There  is  a  marked  family  stain,  evident  as  soon  as  a 


ANSWERS    TO    QUESTIONNAIRE  251 

card  index  of  those  affected  was  prepared.  The  use  of 
mercury  and  iodide  of  potash  caused  the  lesions  to  at 
once  improve  and  the  disease  has  now  been  brought  to 
such  a  state  that  there  are  no  open  lesions  in  any  of  the 
inhabitants  except  in  the  new  cases  that  continue  to  de- 
velop from  time  to  time  and  in  those  who  neglect  their 
treatment.  The  number  of  these  cases  is  very  few,  as 
all  those  who  are  known  to  have  the  disease  are  under 
supervision  and  treatment,  and  any  neglecting  to  take 
their  treatment  are  punished.  The  disease  is  a  very  in- 
teresting chapter  in  syphilis.  The  common  evidences  of 
inherited  syphilis,  Hutchinson's  teeth,  snuffles,  and  the 
like  are  not  seen  at  all.  The  Avomen  are  not  subject  to 
miscarriage  any  more  than  those  known  not  to  have 
syphilis.  The  average  age  at  the  onset  of  the  disease  is 
25.7  years.  There  is  no  record  of  a  primary  syphilitic 
sore  having  been  seen  in  a  Chamorro,  to  my  knowledge, 
and  no  member  of  the  enlisted  force  of  the  navy  or 
marine  corps  has  received  syphilitic  infection  from  a  na- 
tive of  Guam.  The  evidences  of  syphilis,  excepting 
iritis  (primary)  and  certain  of  the  affections  of  the  brain 
and  nervous  system  (dementia  and  tabes),  have  all  been 
seen.  Keratitis  is  fairly  common,  but  yields  readily  to 
treatment ;  bone  involvement  is  common  and  early  para- 
Ij^tic  l)rain  conditions  were  seen ;  involvement  of  the  liver 
and  spleen  and  other  organs  was  seen,  and  ^delded 
promptly  to  mixed  treatment.  Though  many  attempts 
were  made  to  demonstrate  the  presence  of  treponema 
none  were  successful.  Salvarsan  arrived  in  May,  1911, 
but  at  the  time  of  my  departure  the  older  cases  in  which 
it  had  been  tried,  had  not  given  any  results.  No  history 
of  syphilis  could  be  obtained  from  any  of  the  natives 
or  from  the  Spaniards  remaining  on  the  island.  AYe 
were  satisfied  that  the  original  infection  had  taken 
place  some  generations  ago.  The  evidences  of  involve- 
ment of  the  circulatory  system  were  negative,  only  one 


252  TROPICAL    SUEGERY    AXD    DISEASES 

case  of  aneurysm  was  kno^\'Ti  to  exist,  and  this  was  in 
a  woman  of  about  sixty  years  of  age.  It  is  not  known 
whether  a  Wassermann  was  made  in  her  case.  The  Was- 
sermann  was  made  in  one  hundred  cases,  not  selected, 
and  maiw  of  them  had  taken  mixed  treatment  for  about 
one  year.  At  the  time  of  my  leaving  we  had  339  cases 
who  had  had  the  disease;  one  case  was  a  leper  and  the 
gangosa  lesions  healed  promptly  under  the  use  of  mixed 
treatment.  No  lesions  Avere  found  that  differed  from 
those  seen  in  syiDliilis  except  that  the  disease  presented 
none  of  the  secondary  skin  eruptions  and  its  course  was 
not  so  severe  as  in  untreated  cases  in  our  o^Ml  x^eople. 

A  Comparison  o|  Certain  Diseases  Among  Natives  and 
in  the  Observer's  Homeland 

KoREA.^ — Intestinal  diseases  are  less  virulent,  while 
throat  diseases,  measles,  and  scarlatina  are  more  so. 
Lung  diseases  are  more  rapid  in  their  progress.  Em- 
pyema, more  prevalent.  Skin  affections  are  more  prev- 
alent than  in  the  United  States.'  Syphilis  usually  of 
a  milder  form,  chiefly  manifest  in  nasal  and  palatal  de- 
struction, but  rather  uncommon  elsewhere.  Measles  are 
common  and  severe ;  ear  and  intestinal  comj)lications  oc- 
cur frequentl}".  General  spinal  and  peripheral  nerve 
lesions,  more  uncommon  than  in  United  States.  Tabes 
has  as  yet  not  been  observed.  Simple  cases  of  goiter  are 
generally  reported  as  uncommon  and  those  with  exoph- 
thalmic symptoms  have  not  l3een  ol^served.  In  Kangkai 
and  that  section  of  Korea  simple  goiter  is  cpiite  common 
in  various  stages  of  development.  The  Koreans  have  a 
saying  that  anyone  who  drinks  the  water  that  drains 
from  the  decaying  roots  of  the  edil^le  pine  will  develop 
the  disease.  Typhus  is  very  coimnon  at  Taiku  and  in 
the  South  generally,  and  it  is  apparently  as  common  now 
as  previously.  Although  the  s^miptoms  are  not  so  se- 
rious as  among  foreigners,  the  Koreans  are  very  much 


ANSWERS    TO    QUESTIONNAIRE  253 

afraid  of  it  and  recognize  its  contagions  nature.  Cases 
of  rabies  occur  from  time  to  time  in  most  every  section 
of  Korea.  For  a  number  of  years  the  Severance  Hos- 
pital was  kept  in  readiness  to  treat  with  virus  any  case 
that  might  be  sent  in.  Recently  the  government  hospi- 
tal laboratories  have  instituted  tliis  department  so  that 
private  institutions  need  not  continue  this  work.  Aii}^- 
one  now  can  obtain  a  full  treatment  for  $3.75  gold.  Gan- 
grene of  the  fingers  and  toes  was  noticed  in  several  cases 
of  snake  bite.  One  patient  with  a  large  patch  of  anes- 
thesia on  the  leg  attributed  this  to  a  snake  bite  some  years 
before.  Bites  from  centipedes  only  cause  a  swelling 
with  urticaria-like  spots  and  the  pain  goes  away  rapidly 
after  the  use  of  ammonia  solution.  There  was  no  siorue 
seen  in  natives.  Relapsing  fever  is  fairly  common 
about  Taiku,  Intestinal  diseases,  diseases  of  the  bron- 
chi, and  skin  diseases  are  more  common  here  than  in 
the  United  States.  Endemic  hemoptysis  very  common  in 
the  most  northern  province  and  now  that  we  are  making  a 
systematic  daily  sputum  examination  the  cases  are  in- 
creasing.   Smallpox  cases  are  seen  every  winter, 

Samoa.^ — There  are  five  diseases  which  are  commonly 
met  with;  namely,  granular  conjunct;ivitis  (trachoma), 
Samoan  conjunctivitis  (diplococci),  meningitis,  several 
forms,  otitis  media,  purulent,  and  fish  poisoning.  Gran- 
ular conjunctivitis  presents  all  the  complications  and  se- 
quelae of  trachoma  though  clinically  its  features  are  a 
little  less  severe  and  its  course  a  little  less  rapid  than 
is  usual  in  trachoma.  Nevertheless,  the  two  diseases 
are  practically^  the  same.  The  school  children  were  ex- 
amined by  eversion  of  the  lids  and  the  different  schools 
showed  30  per  cent  to  60  per  cent  of  the  children  suf- 
fering from  this  disease.  Over  five  hundred  examinations 
were  made.  Blindness  partial  and  complete  is  very 
common  in  Samoa  and  much  of  it  has  been  thought  to 
be  due  to  this  condition.    Acute  Samoan  conjunctivitis 


254  Tropical  surgery  and  diseases 

is  a  highly  contagions  endemic  disease  of  the  conjunc- 
tivae ocnlar  and  palpebra;  an  acute  purulent  conjuncti- 
vitis. It  affects  whole  families  and  villages  and  will 
recur  mau}^  times  unless  controlled.  Silver  salts  will 
cure  even  very  severe  cases  in  a  few  da3^s.  The  con- 
dition closety  simulates  gonorrheal  ophthalmia,  but  is 
less  severe.  It  is  caused  by  a  diplococcus  differing  only 
slightly  from  the  gonococcus  but  said  to  have  different 
cultural  reactions.  (See  article  by  Dr.  P.  S.  Rossiter, 
U.S.N.,  U.  S.  Naval  Medical  Bulletin,  1909.) 

Meningitis  is  one  of  the  common  causes  of  death  in 
young  children.  More  than  six  deaths  occurred  in  one 
3^ear  out  of  a  total  of  less  than  three  hundred  from  this 
cause  alone.  Two  of  these  cases  were  shown  to  have  a 
turbid  spinal  fluid  with  many  leukoc^^tes  and  an  intracel- 
lular diplococcus.  They,  hoAvever,  failed  to  respond 
to  an  injection  of  Flexner's  antimeningococcic  serum. 
Three  of  these  cases  showed  a  clear  fluid  Avith  a  few 
mononuclear  leukoc^^tes  and  no  bacteria.  They  were  be- 
lieved to  be  tuberculous.  The  others  were  of  unlviiown 
origin.  CouAmlsions  general  and  prolonged  were  a 
prominent  symptom.  All  children  were  well  nourished 
and  died  a  few  hours  after  onset.  It  was  with  the  great- 
est difficulty  that  the  superstitious  natives  could  be  per- 
suaded to  let  the  doctor  see  these  cases.  They  con- 
sidered them  hopeless  from  the  onset.  Otitis  media  is 
only  moderately  common  among  the  natives  and  gives 
rise  to  very  few  complications  and  responds  fairly  well 
to  treatment.  Most  of  the  cases  are  apparently  caused 
by  the  native  habit  of  cleaning  the  ears  with  a  quill. 
Fungus  infections  of  the  external  canal  have  not  been 
observed. 

Fish  poisoning:  A  mollusk  called  "Matamalu"  is 
used  by  the  native  as  a  food,  when  cooked.  Occasionally 
a  child  Avill  eat  this  before  cooking.  Symptoms  of  acute 
gastrointestinal  irritation  ensue  followed  by  a  peculiar 


ANSWERS    TO    QUESTIONNAIRE  255 

state  of  stupor  and  marked  dyspnea  not  milike  a  very 
severe  attack  of  bronchial  asthma.  Death  ma}^  ensue  in 
a  few  hours.    Recovery  is  the  rule. 

Guam." — Hypertrophy  of  the  prostate  is  very  rare. 
Varix  of  all  kinds  extremely  rare.  Pneumonia  not  very 
common,  but  when  it  occurs  has  a  greater  number  of 
cases  of  empyema  than  is  common  with  our  people.  For 
the  nuinl)er  of  cases  of  tuberculosis  of  the  lungs  that  exist, 
the  percentage  of  cases  of  involvement  of  the  bones,  peri- 
toneum, meninges  and  skin  is  very  small.  Abdominal 
tumors  are  rare  and  the  general  surgical  clinic  Avas 
smaller  than  I  have  ever  seen  in  a  12,000  poi^ulation. 
Accident  work  was  very  rare  and  we  had  almost  as  many 
accidents  among  the  few  Japanese  on  the  island  as  we  had 
with  all  of  the  natives. 

BIBLIOGRAPHY 

iCottle,  George  F.,  Surgeon,  U.  S.  Navv :  Personal  communication,  Novem- 
ber, 1911. 

20clell,  H.  E.,  Surgeon,  U.  S.  Navv:  Personal  communication,  November, 
1911. 

sSmith,  H.  Austin,  Major,  I.  M.  S.,  Principal  of  the  Medical  School,  Agra, 
India:       Personal    communication    November,    1911. 

4Page,  Henrv,  Major,  U.  S.  Army  Medical  Corps:  Personal  communica- 
tion, 1911. 

sSnell,  John  A.,  Soochow  Hospital,  Soochow,  China :  Personal  communica- 
tion, 1911. 

eHoUenbeck,  H.  S.,  Angola,  Portuguese  West  Africa :  Personal  communi- 
cation, December,  1914. 

"Paul,  S.  C,  Senior  Surgeon,  General  Hosi^ital,  Colombo,  Ceylon:  Per- 
sonal communication,  1911. 

sLandsborough,  David,  Mission  Hospital,  Shoka,  Formosa :  Personal  com- 
munication, 1911. 

f'Rej^ort  on  Diseases  in  Korea,  edited  by  Dr.  Ralph  G.  Mills  of  Seoul,  Korea. 
A  symposium  by  physicians  practicing  in  Korea  for  an  average  of 
nine  years  each.  This  personal  communication  is  based  upon  the 
statements  of  sixteen  physicians  who  were  assembled  in  the  annual 
meeting  iii  Seoul,  September  30  to  October  2,  1911.  The  names  of 
the  contributors  with  station  and  years  of  experience  in  medical 
work  in  Korea  are  as  follows:  Oliver  R.  Avison,  IS  years,  and  J.  W. 
Hirst,  7  years,  Seoul ;  Hugh  Currcl,  9  years,  Chinju ;  E.  Douglass 
Follwell,  16  years,  and  Rosetta  S.  Hall,  21  years,  J.  Hunter  Wells,  16 
years,  and  E.  de  M.  Stryker,  7  years,  Pyeng  Yang ;  W.  O.  Johnson, 
14  years,  Taiku ;  I.  M.  Miller,  1  year,  Yeng  Byen ;  Ralph  G.  Mills,  3 
years,  Kangkai ;  A.  H.  Norton,  3  years,  Haiju ;  W.  C.  Purviance, 
3  years,  Chongju ;  W.  T.  Reid,  4  years.  Song  Do ;  J.  B.  Ross,  7  years, 
Wonsau ;  J.  D.  Van  Buskirk,  2  years,  Kongju ;  Hugh  W.  Weir,  7 
years,  Chemulpo. 


256  TROPICAL    SURGERY   AXD    DISEASES 

loBarry,  C,  Major,  I.  M.  S.,  Superintendent,  Civil  General  Hospital,  Ran- 
goon, Burma :     Personal  communication,  1911. 

iiHarstou,  G.  Montague,  Oplithalmic  Surgeon,  Tung  Wa  Hospital,  Hong- 
kong, China:      Personal  communication,  1911. 

isphillips,  E.  Margaret,  Saint  Agatha  Hospital,  Ping  Yin,  Shantung,  China: 
Personal  communication,  1911. 

isPlummer,  W.  E.,  Wenchow,  Chekiang,  China:  Personal  communication, 
1911. 

i^Turner,  C.  A.,  Medical  Officer,  Witwatersrand  Native  Labor  Association 
Limited,  Johannesburg,  South  Africa :  Personal  communication, 
1911. 

15U.  S.  Army  Board  for  the  Study  of  Tropical  Diseases,  Manila,  P.  I.,  com- 
posed of  Major  Weston  P.  Chamberlain,  Capt.  Edward  B.  Vedder, 
First  Lieut.  John  E.  Barber :     Personal  communication,  1911. 

leRoss,  R. :  Malaria  and  the  Transmission  of  Diseases,  The  Huxley  Lec- 
ture, Lancet,  London,  Xovember  7,  1914. 

I'Ochsner,  Emma  J.:     Bull.  Manila  Meet.  Soc,  Feb.,  1913. 

isCastor,  R.  H.,  Swebo,  Burma:     Personal  communication,  1911. 

isDeSilva,  A.  M.,  General  Hospital,  Colombo,  Ceylon:  Personal  communica- 
tion, 1911. 

2oPhalen,  Jos.  M.,  and  Nichols,  Henry  J. :  Journal  of  Science,  1908,  Sec. 
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APPENDIX 


SURGEEY  OF  THE  SPLEEX 

The  Relation  of  the  Spleen  to  Certain  Anemias*  (William  J.  Mayo). — 

Eeceiitly,  as  a  result  of  the  study  of  the  pathology  of  the  living,  largely 
from  material  obtained  at  the  operating  table,  more  accurate  knowledge 
of  the  function  of  the  spleen  has  been  gained  although  in  this  we  are 
still  woefully  lacking  as  compared  to  our  knowledge  of  the  other  organs 
of  the  body. 

The  Eelatiox  of  the  Spleex  to  the  Liver  axd  Digestive  Tract. — Tlie 
spleen  and  liver  are  closely  associated  in  function.  The  liver  is  es- 
sential to  life,  the  spleen  is  not.  The  liver  acts  as  a  gigantic  means  of 
defense  against  poisons,  both  parasitic  and  chemical,  which  would  other- 
wise reach  the  general  circulation  from  the  gastrointestinal  tract  through 
the  radicals  of  the  portal  vein.  This  is  well  shown  in  cancer  of  the 
rectum  and  intestine,  which  through  the  portal  circulation,  often  de- 
velops embolic  processes  in  the  liver  though  seldom  in  the  lung.  Can- 
cer of  the  stomach,  on  the  other  hand,  by  reason  of  direct  commu- 
nications with  the  general  circulation  through  the  diaphragm  as  well 
as  through  the  portal  vein  frequently  develops  secondary  cancer  in 
the  lungs  as  well  as  in  the  liver. 

The  splenic  artery  arises  from  the  celiac  axis,  the  same  source  which 
supplies  the  pyloric  end  of  the  stomach  and  upper  duodenum,  the  liver 
and  pancreas,  all  of  which  are  derivatives  of  the  foregut,  and  all  or- 
gans concerned  in  the  proper  preparation  of  food  products  for  diges- 
tion and  absorption,  as  in  them  also  the  venous  return  of  the  spleen 
becomes  part  of  the  portal  circulation.  The  vascular  system  of  the 
spleen  is  large  and  is  curiously  arranged,  inasmuch  as  the  walls  of  the 
blood  vessels,  except  the  endothelial  lining,  are  absent  and  the  blood 
comes  in  direct  contact  with  the  splenic  pulp. 

The  spleen  contains  a  considerable  amount  of  noustriated  muscle 
fiber  and  elastic  tissue,  but  only  a  very  scanty  supply  of  nerve  tissue, 
and  that  largely  from  the  sympathetic.  Every  organ  of  important  in- 
ternal secretion  is  very  closely,  if  not  organically  associated  with 
sympathetic  nerve  tissue.  Xote  the  adrenals  and  hyj)ophysis,  part  glan- 
dular and  part  sympathetic  ganglia.  This  close  relationship  of  the 
glandular  secretion  with  the  sympathetic  nervous  system  enables  wide- 
spread effect,  so  that  the  internal  secretions  may  be  said  to  play  on 
the  sympathetic  nervous  system  as  the  fingers  play  on  a  piano.  The 
scanty  nerve  supply  of  the  spleen  shows  that  it  does  not  produce  an 
important   internal   secretion.      Its   function   must   be   closely   associated 


*Jour.  Indiana  Med.  Assn.,  Nov.   15,  1915,  viii.  499-504.     Abstracted  from  Collected 
Papers,   Mayo   Clinic,    1916. 

257 


258  TROPICAL,    SURGERY    AND    DISEASES 

with  metabolism,  shown  by  enlargement  during  the  digestive  period 
and  contraction  following  digestion.  That  these  physical  changes  are 
brought  about  through  the  blood  stream  seems  assured  since  epinephrin 
solution  in  the  circulation  will  cause  the  sx^leen  to  contract  one-third 
in  size,  as  noted  by  Elliott  and  Kanavel.i 

The  idea  that  the  spleen  is  an  obsolete  organ  of  little  function  is 
not  tenable,  as  Eccless  has  pointed  out.  The  outstanding  fact  in  a 
retrogressing  organ  is  the  reduced  blood  supply.  The  tonsils,  for  ex- 
ample, were  at  one  time  supposed  to  be  retrogressive,  but  the  fact  that 
the  tonsil  has  five  sources  of  blood  supply  shows  that  it  is  not  obsoles- 
cent, yet  it  is  not  essential  to  life  and  when  diseased  has  great  poten- 
tiality for  harm.     This  is  quite  analogous  to  the  spleen. 

It  would  appear  that  the  spleen  removes  from  the  circulation  not 
only  cellular  elements  of  definite  food  value,  but  also,  when  unable 
to  properly  care  for  these  products,  sends  them  to  the  liver  for  elabo- 
ration into  energy-producing  substances,  on  the  one  hand,  and  de- 
struction of  various  toxic  agents  on  the  other,  that  nothing  of  value 
may  be  eliminated  and  that  dangerous  products,  wherever  produced, 
may  be   rendered  harmless. 

The  relation  of  all  animal  life  to  food  supply  is  of  first  importance. 
It  is  a  trite  saying  that  nature  abhors  waste.  The  amount  of  energy 
nature  can  produce  in  the  living  with  a  limited  amount  of  food  has 
no  imitators  in  man 's  handiwork.  One  must  confess  that  whatever 
his  mental  and  moral  deficiencies,  and  they  are  certainly  great,  as  a 
machine,  man  has  no  equal.  The  degenerated  cellular  elements  from 
the  blood  and  even  the  food  values  of  ingested  parasites  are  conserved. 
It  has  been  shown  that  the  phagocytes  of  the  body  depend,  to  a  con- 
siderable extent,  on  ingested  bacteria  for  their  nutrition  (Hisss),  Stohrs 
and  Adami  have  shown  that  the  leukocytes  of  the  body  pass  out  on 
the  free  surface  of  the  intestine  and  return  loaded  with  bacteria  and 
particles  of  fat,  and  that  the  pigmented  areas  of  the  liver  are  de- 
rived from  the  coloring  matter  of  slaughtered  bacteria.  In  the  same 
manner  the  fluids  of  the  intestinal  tract  are  redistilled  in  the  proximal 
colon  after  being  used  mechanically  to  float  the  food  products  down  the 
small  intestine  and,  that  nothing  may  be  wasted,  bring  them  in  contact 
with  the  valvulae  conniventes,  which  are  to  man  what  roots  are  to  a  tree. 

The  close  association  of  cirrhosis  of  the  liver  with  enlargements  of 
the  spleen  has  long  been  noted.  In  primary  cirrhosis  of  the  liver  the 
spleen  is  enlar,ged  and  in  splenic  anemia  with  splenomegalia  the  ter- 
minal stage  shows  cirrhosis  of  the  liver.  In  some  cases,  much  diffi- 
culty is  experienced  in  determining  whether  the  hepatic  cirrhosis  is 
primary  and  the  splenomegalia  secondary,  or  the  contrary.  Nearly 
thirty  years  ago  Gregory*  rather  picturesquely  stated  that  nature  had 
three  ways  of  protecting  the  organism  against  noxious  agents:  First, 
by  absorption,  destruction  and  elimination  through  natural  processes; 
second,  by  encapsulation  of  such  harmful  substances  as  it  was  unable 
completely  to   destroy   or   eliminate,   of   which   the   encysted  bullet   is   a 


APPEXDIX  259 

gross  example;  and  third,  by  extrusion,  as  in  the  spontaneous  opening 
and  discharge  of  infective  organisms  in  phlegmons.  It  would  seem 
probable  that  in  cirrhosis  of  the  liver  the  second  of  these  methods 
was  in  operation.  It  has  been  suggested  that  in  chronic  alcoholism, 
for  example,  the  liver,  finally  unable  to  destroy  and  eliminate,  at- 
tempts to  encapsulate  a  diffuse  poison  and  that  the  contraction  of 
this  scar  tissue  produces  the  cirrhosis.  But  cirrhosis  of  the  liver  is  by 
no  means  confined  to  alcoholics.  It  is  often  seen  in  comparatively 
young  people  and  those  who  have  never  used  alcohol.  It  probably 
would  not  be  far  wrong  to  say  that  certain  toxic  substances  circulating 
in  the  blood  may  be  gathered  into  the  spleen  and  sent  thence  to  the 
liver  for  destruction,  and  that  chronic  hepatic  insufficiency  might  even- 
tually lead  to  the  production  of  cirrhosis  of  the  liver,  on  one  hand, 
and  on  the  other,  show  its  effect  on  the  spleen,  as,  a  splenomegaly 
with  resulting  anemia,  as,  no  matter  what  the  cause  of  the  splenic 
hypertrophy  may  be,  an  increased  capacity  for  destruction  of  the  red 
cells  seems  liable  to  develop.  Syphilitic  cirrhosis  of  the  liver  with 
splenomegalia  is  an  example  of  the  nonalcoholic  type  of  disease  and 
splenectomy  in  these  cases  promptly  relieves  the  anemia,  although  the 
spleen  itself,  on  pathologic  examination,  may  show  no  evidence  of  spiro- 
chetal action. 

Certain  it  is  that  the  removal  of  the  spleen  has  been  of  very  great 
benefit  in  some  cases  of  cirrhosis  of  the  liver,  especially  of  the  Hanot 
type.  These  experiences,  however,  have  been  too  recent  to  enable  any 
conclusion  to  be  drawn,  but  among  the  group  of  splenic  anemias  in  which 
a  greatly  enlarged  spleen  has  been  removed  and  cirrhosis  of  the  liver  was 
present  with  ascites,  etc.,  patients  have  been  apj)arently  cured,  and  the 
cures  have  now  lasted  long  enough  to  enable  us  to  say  that  at  least  the 
cause  of  a  progressive  and  heretofore  fatal  malady  has  been  removed. 
We  could  not  expect  a  cirrhosed  liver  to  return  to  normal,  but  the  prog- 
ress of  the  cirrhotic  process  has  been  interrupted  and  the  remaining  he- 
patic tissue  has  been  sufficient  to  carry  on  function.  Of  the  important 
organs  of  the  body,  the  liver  is  one  of  the  few  which  has  the  power  of 
regeneration.  If  half  of  the  liver  of  a  dog  be  removed,  it  will  be  re- 
stored in  a  few  months.  In  the  kidney  regeneration  does  not  take  place. 
It  is  rather  a  hypertrophy  of  the  original  tissue  of  the  kidney  than  a 
tnie  reproduction  of  lost  tissue  from  existing  tissue  which  occurs  under 
similar  experimentation. 

If  we  accept  the  idea  that  the  spleen  removes  from  the  blood  nox- 
ious agents,  are  we  to  conclude  that  all  the  circulatory  blood  must  go 
through  the  spleen  for  this  purpose;  or  is  there  an  attraction  between 
organs  and  the  arterial  supply  of  the  body,  that  is,  do  certain  organs 
definitely  attract  substances  circulating  in  the  blood?  Eosenows  has 
shown,  for  example,  that  the  streptococci  cultured  in  the  gall  bladder 
are  definitely  attracted  to  the  gall  bladders  of  experimental  animals 
when  injected  into  the  circulation.  This  is  also  equally  true  of  other 
oigans — the    appendix,   the   stomach,    etc.,   so   that   he   has   been   able   to 


260  TROPICAL  SURGERY  AND  DISEASES 

produce  definite  infections  of  organs  with  injections  of  bacteria  properly- 
cultured. 

The  Relation  of  the  Spleen  to  the  Blood. — The  spleen  i&  found  in  all 
red-blooded  animals.  The  ancestral  blood  corpuscle,  from  which  both 
red  and  white  have  their  origin,  is  probably  the  mesenchyme  cell,  a 
form  of  lymphocyte  which  appears  first  in  the  fetal  blood.  The  most 
primitive  blood  is,  therefore,  white  blood.  This  is  found  in  the  fetus 
before  the  red  blood  appears.  All  animals  that  have  only  one  kind 
of  blood  have  white  blood.  As  the  scale  of  animal  life  ascends,  red 
blood  begins  to  appear  and  nearly  all  the  conditions  of  the  blood  of 
the  different  anemias  is  the  normal  blood  of  some  of  the  lower  animals. 
In  fetal  life  all  of  the  lymphoid  and  adenoid  structures  of  the  body, 
the  bone  marrow,  the  spleen  and  in  its  early  stage,  probably  also  the 
liver,  are  blood-forming  organs.  The  liver  loses  this  function  long  be- 
fore birth.  In  leukemia,  all  of  these  primitive  organs,  including  the 
spleen  and  liver,  for  some  unknown  reason,  begin  to  produce  embryonic 
white  blood,  just  as  in  cancer  there  is  an  unlimited  production  of  em- 
bryonic epithelial  cells  and  in  sarcoma  of  embryonic  connective-tissue 
cells.  After  birth,  the  spleen  continues  to  produce  a  certain  number 
of  leukocytes,  as  shown  by  the  fact  that  the  splenic  vein  contains  a 
higher  percentage  of  leukocytes  than  the  other  veins  of  the  body,  but 
does  not  produce  erythrocytes.  Oslers  states  that  after  severe  hemor- 
rhages the  spleen  may  temporarily  produce  red  cells. 

It  has  also  been  definitely  shown  that  worn  out  red  corpuscles  are 
strained  out  in  the  spleen  and  destroyed;  thus  the  splenic  vein  eon- 
tains  a  higher  percentage  of  hematin  than  other  veins  of  the  body. 
In  disease  we  may  surmise  that  excess  of  s^ilenie  function  destroys  red 
corpuscles  which  are  not  worn  out  and  the  condition  becomes  one  which 
we  speak  of  as  si)lenic  anemia  or  hypersplenism,  and  that  the  exceed- 
ingly rare  condition  of  excess  of  red  cells  in  the  blood  called  polycy- 
themia may  be  due  to  deficiency  of  function  of  the  spleen  and  associated 
organs — a  hyposplenism.7  This  explanation,  however,  is  undoubtedly 
too  simple  and  does  not  take  into  account  the  possibility  of  the  spleen 
interfering  in  some  unknown  manner  with  the  production  of  red  cells 
in  the  bone  marrow.  It  is  more  probable,  however,  that  in  certain 
conditions  of  disease  red  cells  are  sensitized  in  other  tissues,  as  shown 
by  the  increased  fragility  of  the  red  cells  (Chauffards  and  Widals), 
and  are  then  destroyed  in  the  spleen.  Since,  when  the  spleen  is  re- 
moved in  cases  of  primary  anemia,  pernicious  anemia  and  in  hemolytic 
jaundice,  it  is  found  crowded  with  disorganized  erythrocytes,  this  hy- 
pothesis seems  the  more  logical. 

Of  great  significance  is  the  knowledge  that  the  spleen  and  possibly 
other  organs,  of  themselves  not  necessary  to  life,  may  be  tlie  link 
easily  broken  in  an  otherwise  fatal  chain.  From  the  fact  that  the  spleen 
is  not  necessary  to  life  and  yet  that  its  remo-^'al  may  definitely  check 
certain  hopelessly  progressive  blood  dyscrasias,  one  must  conclude  that 
the  spleen  is  not  the  cause  but  rather  the  agent  of  destruction,  as  in 


APPENDIX  261 

liemolytic  jaundice,  and  that  when  the  spleen  is  removed  the  noxious 
substances  are  rendered  innocuous  elsewhere  under  niore  favorable  con- 
ditions, although  what  becomes  of  these  toxic  agents  after  the  spleen  is 
removed  we  have  no  means  of  knowing.  Be  this  as  it  may,  clinical  ex- 
perience has  definitely  shown  that  many  of  those  anemias  associated 
primarily  with  an  enlarged  spleen  and  secondarily  with  cirrhosis  of  the 
liver  are  definitely  cured  by  removal  of  the  spleen. 

Anemias  of  Possible  Splenic  Origin. — In  grouping  these  anemias  much 
ditficulty  is  experienced  and  the  accepted  terms  of  designation  concern, 
to  a  great  extent,  syndromes. 

Splenic  Anemia. — The  group  called  the  splenic  anemias  shows  rather 
a  definite  clinical  picture,  for  example,  secondary  anemia,  leukopenia, 
enlarged  spleen,  hemorrhage  from  the  stomach  and,  in  the  late  stages, 
the  characteristics  described  by  Banti,io  cirrhosis  of  the  liver,  ascites, 
etc.,  a  disease  most  common  in  young  adults.  Children,  however,  are 
not  infrequently  subject  to  the  disease  of  the  adult  type  and  it  is 
possible  that  the  "pseudoleukemic  anemia"  of  infants  or  von  Jaksch's 
disease  is  also  a  manifestation  of  the  same  condition  (Giffinii).  In 
von  Jaksch's  disease  there  is  a  leukocytosis  which  is  chiefly  a  lympho- 
cytosis together  with  a  diminution  of  erythrocytes,  a  large  spleen  and 
cachexia.  In  this  condition  infants,  for  physiologic  reasons,  usually 
show  an  excess  of  leukocytes  up  to  30,000  or  more,  older  children  more 
often  developing  the  condition  seen  in  adults  with  leukopenia,  but  even 
in  adults  the  leukocytes  may  be  in  excess  in  otherwise  typical  cases  of 
splenic  anemia. 

In  our  clinic  to  Sept.  20,  1915,  seventy-one  splenectomies  have  been 
performed  w^ith  six  deaths.  Twenty-nine  were  in  cases  of  definite  splenic 
anemia.  All  the  patients  recovering  from  the  operation,  with  five  ex- 
ceptions, have  remained  quite  well  in  spite  of  the  fact  that  some  were 
in  the  late  stages  of  the  disease,  that  is,  markedly  advanced  h.epatic 
cirrhosis,  ascites,  and  jaundice  (Gifiinlis). 

Gaucher 's  Disease. — Gaucher 's  disease  or  large-cell  splenomegalia  is 
closely  associated  with,  splenic  anemia  and  early  removal  of  the  spleen 
will  probably  cure  the  condition.  Gaucher 's  disease  is  characterized 
by  a  slowly  growing  spleen,  which  eventually  becomes  of  great  size, 
with  secondary  anemia  and,  in  the  terminal  stages,  the  characteristic 
endothelial  growths  appear  in  the  liver,  lymph  nodes  and  bone  marrow. 
According  to  Brill  and  Mandelbaum,i3  it  always  begins  before  the  thir- 
teenth year  and  averages  twenty  years  before  a  fatal  termination, 
usually  a  terminal  complication. 

Semolytie  Jaundice. — That  hemolytic  jaundice,  in  the  great  majority  of 
cases,  is  due  to  hypersplenism  may  now  be  accepted.  Whether  the  spleen 
is  acting  on  its  own  initiative  or  through  stimulation  of  the  blood  in 
destroying  the  red  cells  we  have  at  present  no  definite  knowledge. 

Five  patients  with  hemolytic  jaundice  have  been  operated  on  in  our 
clinic.  None  of  these  cases  was  of  the  familial  type,  though  all  had 
beigun  in  childhood.     In  this  condition  there  is  an  enlarged  spleen  and 


262  TEOPICAL  SUEGERY  AXD  DISEASES 

constant  moderate  jaundice  of  the  acholuric  type,  that  is,  there  is  bile 
in  the  stool,  absence  of  itching  of  the  skin  and  freedom  from  all  symp- 
toms of  obstructive  jaundice.  Usually  there  is  increased  fragility  of 
the  red  cells  and  an  excess  of  urobilin  and  urobilinogen  in  the  urine 
but  no  bilirubin.  Exacerbations  are  often  preceded  by  typical  crises 
somewhat  resembling  gallstone  colic,  with  increased  temperature,  malaise, 
headache,  loss  of  appetite  and  an  increase  of  the  jaundice.  During  the 
crisis  the  spleen  is  enlarged  and  tender.  In  three  of  our  patients,  two 
under  20  years  of  age,  gallstones  were  present.  Improvement  after 
splenectomy  in  our  cases  was  a  most  remarkable  phenomenon.  The 
jaundice  began  to  clear  within  twenty-four  hours  following  the  splenec- 
tomy and  in  four  days  had  completely  disappeared,  with  complete  res- 
toration of  well-being.14 

There  have  been  attempts,  more  or  less  successful,  to  demonstrate 
essential  differences  between  the  familial  hemolytic  jaundice  of  Min- 
kowskiio  and  the  acquired  disease  of  Hayemie  and  Widal.s  Chauffards 
says  that  in  the  congenital  type  the  disease  shows  itself  more  or 
less  distinctly  from  birth,  and  the  patients  are  "more  icteric  than 
sick,"  while  the  acquired  type  begins  in  adolescence  and  the  patient 
is  "more  sick  than  icteric."  The  congenital  type  may  last  for  a  life- 
time with  the  patient  in  fair  health;  the  acquired  type  is  progres- 
sive  and  leads   to   death   through  anemia  and  its   complications. 

There  is  a  remarkable  similarity  between  cirrhosis  of  the  liver  with 
enlargement  of  the  spleen  and  splenomegalia  with  cirrhosis  of  the 
liver.  Just  so  are  we  impressed  by  the  similarity  between  acquired 
hemolytic  jaundice  and  Hanot's  cirrhosis  of  the  liver.  Both  are  more 
common  in  young  adults  and  are  more  or  less  chronic  in  their  course, 
the  patients  with  hemolytic  jaundice  frequently  living  out  a  life  ex- 
pectancy, and  those  with  Hanot  's  cirrhosis  lasting  from  four  to  ten 
years.  Both  have  enlarged  spleens  accompanied  by  jaundice,  often 
slight,  but  with  exacerbations,  both  may  have  crises  marked  by  pain 
in  the  region  of  the  liver,  and  in  both  ascites  is  usually  absent.  It 
is  very  evident  that  there  is  some  connection  between  hemolytic  jaun- 
dice and  Hanot's  cirrhosis.  That  hemolytic  jaundice  is  definitely  cured 
by  splenectomy  can  be  stated  as  a  fact,  and  growing  experience  leads 
to  the  conclusion  that  improvement  and  sometimes  definite  cure  in 
Hanot's  type  of  cirrhosis  of  the  liver  may  be  effected  by  splenectomy, 
although  in  confusing  types  of  the  disease  with  hemophilic  tendencies 
one  must  be  guarded  in  advising  surgical  treatment. 

Pernicious  Anemia. — It  has  been  kno^^ii  for  many  years  that  pernicious 
anemia  is  often  accompanied  by  a  large  spleen.  Ejii^ingeri"  first 
pointed  out  that  after  the  spleen  was  removed,  in  pernicious  anemia 
an  extraordinary  improvement  in  the  condition  of  the  blood  was  usu- 
ally noted,   and   experience   has  borne   out   Eppinger's   observations. 

Cabotjis  in  discussing  six  splenectomies  for  pernicious  anemia,  said 
he  had  never  seen  such  great  improvement  produced  by  any  medicinal 
agent    as   had   followed   splenectomy;    that   no   medicament   with   which 


APPENDIX  263 

he  was  acquainted  -would  Ijring  up  and  hold  the  red  cells  above 
four  million.  Four  of  his  patients  had  been  incapacitated  for  two 
years  or  more  and  within  a  few  months  following  splenectomy  they 
were  able  to  go  back  to  work.  He  points  out  that  sufficient  time  has 
not  elapsed  to  show  that  these  patients  are  cured,  but  even  as  a 
means  of  producing  a  prolonged  interval  of  well-being  the  splenecto- 
mies have   been  worth   while. 

It  is  true  that  the  spinal  cord  changes  in  pernicious  anemia  have 
not  been  benefited  by  splenectomy  and  they  have  even  progressed  after 
splenectomy  in  spite  of  the  general  improvement  of  the  patient.  Also 
the  blood  in  the  splenectomized  patients  so  far  observed  did  not  en- 
tirely lose  the  characteristic  pernicious  cells  nor  could  we  expect  it 
to  do  so.  We  can  not  expect  the  operation  to  overcome  structural 
changes  in  organs  which  have  been  permanently  damaged,  and  up  to 
the  present  time  the  only  cases  which  have  been  subjected  to  operation 
have  been  largely  those  in  advanced  stages  of  the  disease.  Experience 
shows  that  splenectomy  should  be  resorted  to  early  and  in  these  cases 
cure  may  at  least  be  hoped  for.  The  spleen  has  been  removed  in 
twelve  of  our  cases  of  pernicious  anemia  (Sept.  20,  1915).  The  im- 
proA'ement  in  some  of  these  cases  has  been  remarkable,  but  not  enough 
time   has   yet   elapsed   to   warrant   any   definite   statements  being   made. 

In  reviewing  the  basic  facts  of  splenic  anemia,  hemolytic  jaundice 
and  pernicious  anemia,  the  one  fact  that  stands  out  is  that  there  is  a 
destruction  of  the  red  blood  cells  and  that  this  hemolytic  change  is 
accompanied  by  physical  changes  in  the  spleen.  It  is  interesting  in 
this  connection  that  in  sixteen  of  the  seventy-one  cases  of  splenec- 
tomy in  our  clinic  gallstones  were  found,  and  all  were  in  the  groups  of 
anemias   (forty-seven  cases). 

In  addition  to  these  rather  definite  groups  of  eases,  enlargement 
of  the  spleen  is  found  under  conditions  for  which  through  lack  of 
knowledge  we  have  no  ready  classification,  as  in  certain  diseases  with 
hemoph-iliac  and  purpuric  tendencies,  and  it  may  eventually  be  shown 
that  the  spleen  is  associated  with,  these  conditions  of  the  blood.  Pa- 
tients with  anemia  associated  with  splenomegalia  and  having  high  tem- 
perature, such  as  are  seen  in  the  pregnant  state,  require  further  study. 
I  shall  not  discuss  infections  of  the  spleen,  bacterial  and  protozoal, 
which  give  rise  to  surgical  conditions,  nor  those  anomalies  and  tumors, 
of  which  we  have  observed  some  remarkable  examples.  I  have  pur- 
posely omitted  reference  to  the  pathology  of  the  spleen  itself,  because 
this  study  is  not  as  yet  sufficiently  advanced  to  be  more  than  sug- 
gestive. Wilsoni9  is  now  studying  our  cases  and  is  able  to  show  that 
there  is  a  true  microscopic  pathology  in  these  diseases  which  it  is 
hoped  will  prove  to  be  characteristic. 

Our  knowledge  of  splenic  disease,  like  most  of  our  knowledge  of 
organs  in  concealed  situations,  has  been  the  result  of  study  of  living 
pathology  under  surgical  conditions.  Postmortem  examinations,  which 
were   once   looked  on   as   the  final  word   on   disease  processes,   have   too 


264  TROPICAL    SURGERY   AISB   DISEASES 

often  not  shown  the  chronic  diseases  from  which  people  suffered  during 
life,  but  only  the  disease  from  which  they  died.  Experimentation  on 
animals,  like  the  postmortem,  has  been  of  enormous  A-alue  in  laying 
a  foundation  for  medicine,  but  as  the  animals  themselves  were  not 
diseased,  the  conditions  favorable  to  exact  knowledge  were  not  pres- 
ent, and  experimentation  is  now  seen  in  its  i^roper  light  as  an  aid  to 
understanding  but  not  as  the  final  solution  of  jDroblems  of  the  living. 
But  the  living  pathology  brought  forth  by  the  surgeon  has  in  this 
field,  as  in  others,  enabled  medical  research  to  produce  most  valuable 
material  for  study  and  has  within  the  last  few  years  advanced  our 
knowledge  of  the  physiology,  pathology,  and  therapeutics  of  diseased 
conditions  of  the  spleen  more  than  all  else  that  has  been  done  since 
the  beginning  of   time. 

BIBLIOGRAPHY 

^Elliott,  C.  A.,  and  Kanavel,  A.  B.:     Splenectomy  for  Hemolytic  Icterus,  Surg.,  Gynec. 

and  Obst.,   1915,  xxi,  21. 
-Eccles,    R.    G. :     The   Tonsils  and   the   Struggle   for   Existence,   Med.   Rec,   Xew  York, 

1915,   Ixxxviii,   47. 
^Iliss,  P.  H.:     Some  Problems  in  Immunity  and  tbe  Treatment  of  Infectious  Diseases, 

Arch.  Int.   Med.,  July,   1909,   32. 
^Gregory,  E.  H.:     Cell  Antagonism,  Jour.  Am.   Med.   Assn.,  June   11,  1887,  645. 
^Rosenow,    E.    C. :      Bacteriology    of    Cholecystitis    and    Its    Production   by   Injection   of 

Streptococci,   Jour.   Am.   Med.    Assn.,   Nov.   26,   1914,   1835. 
^Osler,  W. :     The  Principles  and  Practice  of  Medicine,  New  York,  D.  Appleton  &  Co., 

1912. 
'Hemolytic    Jaundice    and    Splenectomy,    Editorial,    Jour.    Am.    Med.    Assn.,    June    17, 

1915,.  255. 
^Chauffard,    A. :      Pathogenie    de    I'ictere    congenital    de    I'adults,    Semaine   Med.,    1907, 

No.  3,  25;  Les  icteres  hemolytiques,  ibid.,  January,   1908;   Cholelithiase  pigmentaire 

dans   un   cas    d'ictere   congenital   hemolytique;    analyse    chemique   des   calculs.    Bull. 

et  mem.  Soc.  med.  de  Hop.,  1912,  xxxiv,  80.     Cited  by  Elliott  and  Kanavel,  Note  1. 
^Widal,    A.,    and    Brule:       Differenciation    de    plusieurs    types    d'icterse    hemolytiques, 

Presse  med.,   1907,   Ixxxi,   641.     Cited  by   Elliott  and   Kanavel,  Note   1. 
lOBanti,    G. :      Arch.    d.    Scuola   d'Anat.   patol.,    1883,   ii,   53;    Cited   by  Eyon,   I.   P.,    Dis- 
eases of  the    Spleen,    Osier's   Modern   Medicine,    1908,   iv,   759. 
"Gififin,  H.   Z. :     Clinical   Notes   on   Splenectomy,   Ann.   Surg.,    1915,   Ixii,    166. 
^-Gififin,    H.   Z.:      Clinical   Notes  on   Splenectomy,   Ann.    Surg.,    1915,   Ixii,    166;    Clinical 

Observations    Concerning    Twenty-seven    Cases    of    Splenectomy,    Am.    Jour.    Med. 

Sc,  1913,  cxlv,  781. 
I'Brill,  N.   E.,  and  Mandelbaum,  F  .S. :     Large-Cell   Splenomegaly   (Gaucher's  Disease), 

Am.   Jour.   Med.   be,    1913,   cxlvi,    863. 
"Those    interested    in    hematogenous   jaundice    should    read   the    recent   contribution   by 

Elliott  and  Kanavel,   Note   1. 
^^Minkowski,    O. :      Ueber   eine   hereditare,   unter   dem   Bilde    eines    chronischen   Icterus 

mit  Urobilinurie,    Splenomegalie   und   Nierensiderosis  verlaufenden   Affection,   Ver- 

Ivandl.   d.   Kong.  f.  inn.   Med.,  1900,  xviii,   316. 
^'Hayem,  G. :     Sur  un  variete  particuliere  d'ictere  chronique,  ictere  infectieux  chronique 

spleno   megalique,    Presse   med.,    1898,   i,    121.      Nouvelle   contribution   a   I'etude   de 

I'ictere  infectieux  chronique   spleno-megalique.  Bull,  et  mem.    Soc.   med.   d.   hop.   de 

Paris,  1908,  Series  3,  xxv,   122. 
"Eppinger,  H. :     Zur  Pathologie  der  Milzfunction,  Berl.  klin.  Wchnschr.,   1913,  1,   1509, 

1572,  2409. 
'■''Cabot,  R. :     Discussion  on  Blood  and  Blood  Diseases,  Jour.  Am.  Med.  Assn.,  June  26, 

1915,  2164. 
'"Wilson,   L.   B. :     Pathology  of  Spleens   Removed   for   Certain   Abnormal   Conditions  of 

the  Blood,  Ann.   Surg.,    1915,   Ixii,    158. 

The  Spleen. — Its  Association  avith  the  Liver  and  its  Eelatiox  to 
Certain  Conditions  of  the  Blood  (William  J.  Mayo)  ." — For  many  years 
when  doing  abdominal  operations,  if  it  could  be  done  without  risk  to 
the    patient,    it    has   been    my   practice    to    make    a   careful    manual    ex- 

*Abstracted    from   Jour.   Am.    Med.    Assn.,   March   4,    1916,   Ixvi,    716-721. 


APPENDIX  265 

amination  of  the  contents  of  the  abdomen.  Thus  I  have  been  im- 
pressed with  the  fact  that  the  spleen  shows  enlargements  and  other 
physical  changes  ratlier  regularly  in  connection  with  diseases  of  the 
liver  and  of  the  blood.  In  papers  on  this  subject  written  at  various 
times,  attention  has  been  called  to  the  fallacy  of  the  physical  ex- 
amination of  the  spleen,  and  it  may  be  said  that  unless  the  spleen 
is  sufficiently  enlarged  to  be  felt  beyond  the  free,  border  of  the  costal 
margin,  the  enlargement  would  probably  not  be  recognized.  At  times 
careful  physical  examination  by  percussion,  for  instance,  has  ap- 
parently revealed  the  area  of  splenic  dullness,  but  on  the  opening  of 
the  abdomen  the  fact  showed  how  fallacious  percussion  had  been. 
Faith  in  these  methods  has  been  due  to  the  fact  that  in  certain  dis- 
eases, like  typhoid,  which  often  end  in  death,  the  spleen  is  generally 
enlarged,  and  w^ith  this  knowledge  at  hand  a  diagnosis  by  percussion 
has  been  made  and  proved  correct  at  necropsy.  By  means  of  the 
roentgen  ray,  the  possibilities  of  accurately  examining  the  spleen  for 
such  enlargements  are  developing.  The  roentgenologist  has  been  able 
to  outline  the  kidneys,  the  liver,  etc.,  as  well  as  the  digestive  and 
thoracic  organs,  with  a  marvelous  degree  of  accuracy,  and  we  may 
expect  that  he  will  accomplish  the  same  for  the  spleen  in  the  near 
future.  The  humiliating  mistakes  made  by  surgeons,  of  which  we  have 
made  our  share,  of  diagnosing  as  splenic  enlargement  a  cancer  of  the 
stomach  or  colon  or  tumor  of  the  kidney,  are  now  avoidable  by  careful 
roentgenographic   exclusion   of  these   organs. 

The  function  of  defense  of  the  liver  is  shown  by  Adami,i  who 
points  out  that  the  leukocytes  of  the  living  body  pass  out  on  the  free 
mucous  surface  of  the  duodenum  and  upper  jejunum,  and  pick  up  bac- 
teria which  they  usually  destroy,  but  should  they  fail  to  destroy  them, 
the  liver  becomes  the  agent  of  destruction,  and  the  pigmented  areas  in 
the  liver  are  derived  from  such  slaughtered  bacteria.  Eesearch.  has 
shown  that  the  phagocytes  of  the  body  are  developed  in  direct  response 
to  bacterial  invasion.  As  Vaughans  has  pointed  out,  the  period  of 
incubation  of  a  disease  is  the  time  which  is  necessary  to  develox?  or 
train  leukocytes  to  bodily  defense.  He  shows  that  the  reaction  we  call 
typhoid  fever  is  a  defense  manifestation,  and  that  preventive  serums, 
such,  as  vaccination  for  smallpox,  typhoid,  etc.,  act  to  educate  the  cells 
of  the  body  to  resistance  against  certain  organisms  and  to  change  the 
proteins  of  the  body  so  that  they  no  longer  act  as  food  for  these 
bacteria.  Vaughan  advances  the  theory  that  bacteria  are  not  vegeta- 
ble organisms  but  parasitic  growths  in  a  distinct  class  by  themselves. 
Eccless  suggests  that  the  phagocytes  of  the  body  live  on  bacteria,  and 
that  the  food  values  of  the  bacteria  are  thus  conserved.  He  looks  on 
the  tonsils  and  other  lymphoid  structures,  such  as  the  appendix,  as 
what  may  be  called  chronic  vaccinators,  since  through  the  tonsils  are 
constantly  permitted  to  pass  a  certain  number  of  bacteria  which  stimu- 
late  the   development   of   phagocytes.     This   shows   that  a  moderate   re- 


26(3  TROPICAL    SURGERY    AXD    DISEASES 

action  in  tlie  tonsil  may  not  always  be  the  cause  of  an  impending  gen- 
eralized  infection,    but    rather    an    early    defense   manifestation. 

It  is  interesting  to  note  liow  the  spleen  is  controlled  in  its  function. 
Stimulation  and  control  is  exerted  over  the  voluntary  parts  of  the  body 
by  the  cerebrospinal  nervous  system,  over  the  involuntary  or  vege- 
tative part  of  the  body  by  the  sympathetic  ganglion  acted  on  the  in- 
ternal secretions.  In  addition,  there  is  the  essential  rhythm  of  non- 
striated  muscle.  The  vegetative  part  of  the  body  was  well  developed 
before  the  organism  had  reached  the  stage  of  a  cerebrospinal  nervous 
system,  a  comparatively  late  development.  The  sympathetic  nervous 
system,  probably  mesoblastic  in  origin  and  now  closely  associated  with 
the  cerebrospinal  nervous  system,  acts  in  association  with  the  internal 
secretion,  and  all  organs  of  important  internal  secretion,  such  as  the 
suprarenals  and  the  hypophysis,  in  which  gland  and  sympathetic  ganglia 
are  present,  are  so  closely  associated  as  to  form  a  single  organ. 

That  the  spleen  does  not  have  an  important  internal  secretion  is 
shown  by  the  fact  that  its  removal  does  not  deprive  the  body  of  any 
important  constituent;  and  that  it  is  not  under  the  complete  control 
of  the  nervous  system  is  shown  by  its  extremely  scanty  supply  from 
Auerbaeh's  plexus.  But  the  spleen  does  have  a  considerable  amount 
of  nonstriated  muscle  fiber,  and  it  is  altogether  probable  that  this  mus- 
cle has  an  important  function  and  possibly  is  responsible  for  the  di- 
gestive  rhythmic   change   in   the   size    of   the   spleen. 

To  go  further  into  the  interesting  phase  of  a  subject  to  which  Keith 
has  called  attention  would  lead  us  far  afield.  Suffice  to  say  that  the 
rhythmic  waves  are  automatically  checked  by  sphincters,  and  in  failure 
of  rhythmic  intestinal  movement  and  sphincter  control  may  lie  the  se- 
cret of  so-called  intestinal  intoxication  and  neurasthenias  of  intestinal 
origin.  The  presence  of  nonstriated  muscle  in  the  spleen  gives  im- 
portant evidence  of  the  primary'  relationship  of  the  spleen  to  the  di- 
gestive system. 

Enlargements  of  the  Spleex. — These  may  be  divided  into  four  groups : 
(1)  new  growths,  (2)  infections,  (3)  enlargements  associated  with  he- 
patic disease,  and   (4)   those  associated  with  the  blood. 

1.  Neiv  Growths. — The  first  will  not  be  considered  at  this  time.  I 
shall  very  brietiy  take  up  the  results  of  splenectomy  in  some  of  the  dis- 
eases in  the  latter  three  groups. 

2.  Infections. — In  so-called  primary  tuberculosis  of  the  spleen  the 
removal  of  the  organ  has  cured  a  few  patients.  It  is  quite  likely,  how- 
ever, that  tuberculosis  is  practically  never,  in  reality,  primary  in  the 
spleen,  and  that  this  diagnosis  is  the  result  of  insufficient  clinical  study. 
Our  one  patient  of  this  type  died  from  general  miliary  tuberculosis  af- 
ter a  temporary  improvement  of  several  months.  In  three  instances  we 
have  removed  greatly  hypertrophied  spleens  from  patients  suffering 
with  chronic  syphilis  and  marked  anemia.  In  one  of  these,  specific 
treatment  had  been  carried  out  for  two  years,  in  another  for  six 
months,    without    satisfactory    improvement    in    the    general    condition    or' 


APPENDIX  267 

the  anemia.     Following  splenectomy,   there  was  marvelous  improvement 
of  the  anemia  in  all  of  them. 

Marked  enlargement  of  the  spleen  is  quite  frequently  present  in  pa- 
tients with  a  history  of  chronic  recurring  septic  conditions.  These 
spleens  are  usually  smaller  than  those  of  splenic  anemia,  although  oc- 
casionally we  have  seen  a  very  large  spleen  filled  with  infarcts.  We 
have  removed  the  spleen  from  seven  patients  with 'histories  of  chronic 
recurring  sepsis.  Patients  of  this  type  usually  have  a  lowered  resis- 
tance, and  cardiorenal  insufficiency  is  most  likely  to  influence  the  ulti- 
mate  i)rognosis   unfavorably. 

3.  Splenic  Enlargements  Associated  with  Hepatic  Disease. — Primary 
cirrhosis  of  the  liver  accompanied  by  enlargement  of  the  spleen  is  re- 
markably similar  to  primary  enlargement  of  the  spleen  with  secondary 
cirrhosis  of  the  liver,  and  in  the  late  stages  of  either  disease  it  is 
very  difficult  to  determine  in  a  given  case  whether  the  process  was 
primary  in  the  liver  or  in  the  spleen.  In  the  same  way  it  is  difficult 
to  differentiate  between  hypertrophic  biliary  cirrhosis  of  the  liver  of 
the  Hanot  type  in  which  there  is  jaundice,  and  hematogenous  jaun- 
dice, which  has  its  origin  in  the  spleen.  Primary  biliary  cirrhosis  of 
the  Hanot  type  is  doubtless  a  rare  disease.  It  may  last  for  from  six 
to  ten  years,  and  the  spleen  as  well  as  the  liver  is  always  enlarged.  It 
is  a  disease  of  young  adult  life.  As  in  hemolytic  jaundice,  there  are 
crises  marked  by  tenderness  in  the  region  of  the  liver  and  spleen  with 
a  temporary  increase  of  jaundice.  In  a  small  number  of  instances  in 
which  Hanot 's  cirrhosis  has  been  diagnosed,  the  spleen  has  been  re- 
moved with  undoubted  benefit,  and  possible  cure.  We  have  seen  one 
such  ease.  Hemolytic  jaundice  can  usually  be  differentiated  by  the  fact 
that  the  fragility  of  the  red  cells  in  the  peripheral  circulation  is  de- 
creased, whereas  in  cirrhosis  of  the  liver  the  resistance  of  the  red  cells 
is  usually  increased.  In  hemolytic  jaundice  urobilin,  but  not  bile,  is 
present  in  the  urine,  and  the  jaundice  is  not  associated  with  itching. 
Yet  to  what  extent  these  cases  of  biliary  cirrhosis  have  been  confused 
with  those  of  hematogenous  jaundice  of  splenic  origin,  and  to  what 
extent  the  SA-ndrome'  which  has  been  called  Hanot 's  cirrhosis  of  the 
liver   actually  exists,   further  investigation  must   decide. 

In  four  instances  we  have  removed  a  greatly  enlarged  spleen  in  pa- 
tients suffering  from  portal  cirrhosis  of  the  liver.  It  is  too  early  to 
know  whether  or  not  the  end-results  will  justify  the  operation.  Three 
of  our  patients,  however,  have  markedly  improved,  and  the  ascites  and 
anemia  have  disappeared. 

It  must  be  evident  to  all  that  the  spleen  is  only  one  avenue  by  which 
noxious  agents  may  reach  the  liver  and  cause  a  cirrhosis.  It  is  proba- 
ble that  a  large  number  of  cirrhoses  have  their  origin  in  the  gastro- 
intestinal tract,  but,  no  matter  what  the  portal  of  entry  may  be,  there 
is  usually   a   concomitant    enlargement   of   the    spleen. 

In  general,  the  common  forms  of  cirrhosis  of  the  liver  may  be  di- 
vided into   three   classes:   first,  portal  cirrhosis,  in  which  the   toxic  ma- 


268  TROPICAL    SURGERY   A^^^-D    DISEASES 

terial  obtains  entrance  through  the  portal  system  and  the  connective 
tissue  proliferation  advances  from  the  portal  spaces  and  in  which  the 
symptoms  are  those  of  portal  obstruction;  second,  biliary  cirrhosis,  in 
which  the  infectious  agent  may  be  either  ascending  from  the  biliary 
tract  or  hematogenous,  and  in  which  the  most  pronounced  clinical  sign 
is  chronic  jaundice,  while  portal  obstruction  comes  on  late;  third, 
mixed  types,  which  are  undoubtedly  not  rare  and  in  which  a  preopera- 
tive  diagTiosis   is   often  impossible. is 

4.  The  Blood. — Splenic  Anemia :  Patients  with  anemias  associated  with 
enlargements  of  the  spleen  are  cured  or  greatly  benefited  by  splenec- 
tomy. The  syndrome  called  splenic  anemia,  the  terminal  stage,  of  which 
is  known  as  Banti's  disease,  may  be  cured  by  removal  of  the  spleen  in 
a  high  percentage  of  cases. 

Clinically,  splenic  anemia  is  an  entity.  The  spleen  is  large;  there  is 
a  definite  anemia  showing  a  reduction  of  reds  and  a  low  hemoglobin, 
and  the  disease  is  progressive,  ending  in  death.  The  process  may  be 
exceedingly  slow  and  at  times  comi^letely  interrupted  in  its  clinical 
symptoms  for  several  years;  but  all  enlargements  of  the  spleen  that 
can  not  be  shown  to  have  some  other  definite  cause  must  be  looked  on 
as  incipient  splenic  anemia.  The  future  history  of  such  cases  will 
finally  prove  the  large  majority  of  them  to  be  of  this  character.  Hem- 
orrhage from  the  stomach  at  times  is  one  of  the  early  symptoms,  even 
before  the  spleen  is  much  enlarged.  These  cases  of  gastric  hemorrhage 
in  which  no  other  origin  can  be  found  should  be  carefully  examined  for 
evidence  of  splenic  anemia.  In  the  later  stages,  after  ascites  has  de- 
veloped, and  the  liver  has  become  cirrhosed,  but  little  may  be  expected 
from  the  removal  of  the  spleen,  and  yet  several  of  our  patients  in  this 
terminal   condition   have   been   cured   by   splenectomy    (Fig.   4). 

Splenic  anemia  with  adult  characteristics  is  not  infrec[uently  seen 
in  childhood,  and  is  promptly  relieved  by  splenectomy.  It  is  Cjuite 
probable  that  the  pseudoleukemic  anemia  of  von  Jaksch  is  merely  the 
infantile  type  of  splenic  anemia,  the  increased  leukocytes  (30,000  or 
more)  being  merely  a  difference  in  the  reaction  of  the  blood  due  to 
infancy  (Giffin).  It  may  be  said  in  this  connection  that  while  leuko- 
penia is  usually  present  in  splenic  anemia,  there  are  a  number  of 
instances  in  which  patients  having  a  moderate  leukocytosis  (20.000  or 
more)  have  been  operated  on  at  various  ages  and  remained  well  after- 
ward. Several  such  patients  operated  on  by  us  were  previously  diag- 
nosed  as  having   true  leukemia,   and  were   treated  for   it. 

Preliminary  to  splenectomy  and,  in  some  cases,  following  it,  trans- 
fusion of  blood  may  be  necessary.  The  blood  of  the  donor  should  al- 
ways be  tested  in  connection  with  the  recipient  for  agglutination  and 
hemolysis. 

BIBLIOCtEAPHY 

lAdami,  J.  G. :  On  Latent  Infection  and  Subinfection  and  on  the  Etiology  of  Hema- 
chromatosis  and  Pernicious  Anemia,  Jour.  Am.  Med.  Assn.,  Dec.  16,  1899,  1509; 
Dec.  23,  1899,  1572. 


APPENDIX  269 

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can   Medical    Association,    1915,    p.    1. 
'Eccles,   R.  G. :     The  Tonsils  and  the   Struggle  for  Kxistence,  Med.   Rec,   New  York, 

1915,  Ixxxviii,  47. 
■'Rosenow,   E.    C. :     Elective  L,ocalization   of   Streptococci,  Jour.  Am.   Med.   Assn.,  Nov. 

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Lancet,  London,   1915,  ii,  371. 
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Canal,  Arch.  Int.  Med.,  October,   1911,  417. 
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^mall  Intestine.  Am.   Tour.   Phvsiol.,  1914.  xxxv,  177;  Further  Studies  on  Intestinal 

Rhythm.  Am.  Jour.   Physiol.,   1915,   xxxvii,   266. 
*Ochsner,   A.   J.:      Constriction  of  the  Duodenum  below  the   Entrance  of  the   Common 

Duct,  and  Its  Relation  to  Disease,  Tr.  Am.  Surg.  Assn.,   1905,  xxiii,  314. 
^Lane,   W.   A.:     The  Kink  of  the  Ileum  in  Chronic  Intestinal    Stasis,   London,   Nisbet, 

1910;  The  First  and  Last  Kink  in  Chronic  Intestinal  Stasis,  Lancet,  London,   1911, 

ii,    1540;   A  Clinical  Lecture  on  Chronic   Intestinal   Stasis,    Brit.    Med.   Jour.,    1912, 

i,   989. 
MHertz,   A.    F. :      The  Ileo-Caecal   Sphincter,   Jour.   Physiol,   1913,  xlvii,   54.     Hertz,   A. 

F.,  and  Newton,  A.:     The  Normal  Movements  of  the  Colon  in  Man,  Jour.  Physiol., 

1913,  xlviii,   57. 
"Bayliss,  W.  M.,  and  Starling,   E.  H.:     The  Movements  and  Inne'-vation  of  the  Small 

Intestine,   Jour.   Physiol.,    1900-1901,   xxvi,   127. 
*^Mall,   F.:      A   Study   of  the   Intestinal    Contraction,   Johns  Hopkins   Hosp.    Rep.,    1896, 

i,  37.  _ 

^'Osler.  W. :     Principles  and  Practice  of  Medicine,  New  York,  D.  Appleton  &  Co.,  1912. 
"Chauffard,    A.:      Pathogenie   de   I'ictere   congenital   de   I'adulte,    Sem.    med.,    1907,    No. 

3,    25;    Les    icteres    hemolytiques,    ibid.,    January,    1908;    Cholelithiase    pigmentaire 

dans    un   cas  d'ictere   congenital    hemolytique;    analyse    chemique   des   calculs.    Bull. 

et  mem.   Soc.  med.  d.   hop.  de  Paris,  1912,  x.xxiv,  80,  cited  by  Elliott  and  Kanavel: 

Surg..   Gynec.   and  Obst.,   1915,   xxi.   21. 
"Widal,    A.,    and    Brule:      Differenciation    de    plusieurs    types    d'icteres    hemolytiques, 

Presse  med.,  1907,  641,  cited  by  Elliott  and  Kanavel.^* 
*"Sappey,    cited   by    Piersol,    G.    A. :      Human    Anatomv,    Philadelphia,    J.    B.    Lippincott 

Company,   1913,   1781. 
^'Eppinger,    H.:      Zur    Pathologie    der    Milzfunktion,    Berl.    klin.    Wchnschr.,    1913,    1, 

1509,  1572,  2409. 
i^Wilson,  L.  B. :     The  Pathology  of  Splenomegaly,   Surg.,   Gynec.   and   Obst.,   1913,  xvi, 

240;  Pathology  of  Spleens  Removed  for  Certain  Abnormal  Conditions  of  the  Blood, 

Ann.  Surg.,  1915,  Ixii,  158. 
i*Giffin   has  been  very  much   interested  in  hepatic   cirrhosis   in   connection   with   splenic 

enlargement.      I   am   indebted   to   him   for   the   clear   statement   of  the   present  view 

of   these    conditions.      Gififin,    H.    Z. :      Splenectomy    for    Splenic    Anemia    in    Child- 
hood and  the  Splenic  Anemia  of  Infancy,  Ann.  Surg.,   1915,  Ixii,  679;   Splenectomy 

in    the    Treatment    of    Splenomegalia,    Associated    with    Syphilis,    Am.    Jour.    Med. 

Sc,  to  be  published. 
^oBrill,  IST.   E.,  and  Mandelbaum,  F.   S. :     Large-Cell  Splenomegaly   (Gaucher's  Disease): 

A  Clinical  and   Pathological   Study,  Am.  Jour.   Med.   Sc,   1913,   cxlvi,   863. 
^'Minkowski,    O. :     L'eber   eine   Hereditare,   unter   dem   Bilde   eines   chronischen   Icterus 
•  mit  Urobilinurie,    Splenomegalie   und   Nierensiderosis  verlaufenden   Affection,    Ver- 

handl.  d.  Kong.  i.  inn.  Med..  1900,  xviii.  316. 
^^Hayem,   G. :      Sur   tin   variete   particuliere   d'ictere   chronique.   ictere   infectieux   chron- 

ique   spleno-megalique,    Presse   med.,    1898,    i,    121;    Nouvelle   contribution   a   I'etude 

de  I'ictere  infectieux  chronique  spleno-megalique.   Bull,   et  mem.    Soc.   med.   d.   hop. 

de  Paris,   1908,   Series   3,  xxv,   122. 
^Cabot,  R.  C. :     Discussion  on  Blood  and  Blood  Diseases,  abstr..  Tour.  Am.  !Med.  Assn., 

June  26,   1915.   2164. 

The  following"  is  from  an  article  on  ''The  Liver  and  Its 
Cirrhoses"  by  William  J.  Mayo,  published  in  the  Jour- 
nal of  file  American  Medical  Association,  May  11,  1918. 

"In  fifty-one  cases  of  splenic  anemia,  in  ^vhiell  ^Ye  have  removed  the 
greatly  enlarged  spleen,  the  relief  to  the  portal  circulation  has  been  im- 
mediate. In  those  eases  in  which  cirrhosis  was  present,  the  ascites  has  now 
disappeared  and  several  patients  have  lived  for  years,  one  for  more  than 
seven,  in  excellent  health.  The  evidence  here  points  to  the  fact  that  the 
original  poison  was  carried  to  the  liver  from  the  spleen  and  theoretically 


2(0  TROPICAL    SrEGEEY   AXD    DISEASES 

is  i^robably  a  protein  derivative,  filtered  from  the  blood.  But  in  five  cases 
of  portal  cirrhosis  ^vith  ascites,  in  which  I  removed  the  enlarged  spleen,  the 
four  patients  who  recovered  were  greatly  improved  both  as  to  their  general 
condition  and  as  to  the  relief  of  the  ascites.  On  first  thought,  it  seemed 
probable  that  in  the  removal  of  such  a  spleen  I  had  checked  the  source  of 
poisoning.  Ou  further  consideration,  another  explanation  appears  possible 
or  even  probable.  With  the  removal  of  the  spleen,  all  the  blood  from  the 
general  circulation,  which  otherwise  would  have  lieen  sent  to  the  liver 
through  the  sj)lenic  vein,  was  prevented  from  going  there,  and  in  this  man- 
ner suificient  blood  had  been  diverted  from  the  liver  to  relieve  the  jjortal 
circulation.  Possibly  both  views  are  more  or  less  correct.  The  results  in 
these  cases  should  encourage  us  to  splenectomize  in  suitable  cases  of  portal 
cirrhosis  in  the  future,  esj)ecially  when  the  spleen  is  enlarged. ' ' 

Giffin,  in  1912,  commenting  on  twenty-seven  cases  of 
splenectomy,  divided  them  into  three  groups:  (1)  splenic 
anemia,  (2)  infections  splenomegaly,  and  (3)  such 
as  wandering  siDleen,  tuberculosis,  cirrhosis  of  the  liver, 
and  pernicious  anemia. 

Clinical  Observations  Concerning  Twenty-seven  Cases  of  Splenec- 
tomy (H.  Z.  Giffin,  Mayo  Clinic).* — The  association  of  enlarged  spleen 
with  anemia  occurs  in  so  many  diseases  and  in  such  a  variety  of  abdom- 
inal conditions  that  a  fuller  knowledge  will  be  necessary  before  one  can 
arrive  at  a  correct  classification  of  splenomegaly.  The  results  of  medical, 
surgical,  pathological,  and  experimental  experience  must  be  reported 
abundantly  before   a   correct   grouping  can  be   even  attempted. 

That  a  certain  picture  conforming  to  splenic  anemia  as  it  is  clin- 
ically described  presents  itself  there  is,  of  course,  no  doubt.  How- 
ever, the  many  factors  that  are  discussed  by  writers  on  the  etiology 
of  this  condition  at  once  make  one  question  the  ad^-isability  of  stamp- 
ing a  given  ease  with  a  certain  stencil.  Syphilis,  malaria,  passive 
congestion  as  a  result  of  portal  obstruction,  thrombosis  of  the  splenic 
or  portal  veins,  the  occurrence  of  Leisehmann-Donovan  bodies,  the  ac- 
tion of  extraneous  toxins,  the  occurrence  of  hemolysis,  the  existence 
of  an  undemonstrated  infectious  agent — these  have  all  been  considered 
as  factors  in  the  causation  of  certain  cases.  And  there  must  be  added 
to  this  list,  after  a  consideration  of  the  cases  herewith  reviewed,  what 
appears  to  be  more  than  an  accidental  association  of  disease  of  the 
gall  bladder,  with  cases  that  can  properly  be  diagnosticated  clinically 
as  splenic  anemia.  Moreover,  at  one  extreme,  there  are  many  histories 
of  short  duration  or  those  without  the  typical  symptomatology  and 
cases  with,  atypical  blood  count,  while  at  the  other  extreme  there  are 
instances  in  which  cirrhosis  of  the  liver  seems  to  form  a  slightly  more 
prominent   part   of   the   picture   than   the    changes   in  the    spleen.     And 


"Abstracted  from  Am.  Jour.  Med.    Sc,  June,   1913,  cxlv,  Xo.   6,   781. 


APPENDIX  271 

apart  from  the  clinical  and  etiological  aspects  there  is  confusion  on 
the  pathological  side.  The  examination  of  spleens  removed  from  pa- 
tients regarded  from  the  clinical  standpoint  as  cases  of  typical  splenic 
anemia  reveals  no  constant  histologic  picture.  Connective  tissue  in- 
crease is  the  common  finding,  but  endothelial  or  lymphocytic  hyper- 
plasia may  predominate  to  such  a  degree  that  the  picture  may  even 
simulate   a    true    tumor. 

Clinical  Notes  on  Splenectomy  (H.  Z.  Giffin,  Mayo  Clinic).* — Many 
types  of  splenomegaly  are  necessarily  represented  in  this  series  and  any 
classification  of  the  cases  is,  of  course,  open  to  discussion  and  criticism. 
On  the  basis  of  their  clinical  and  pathologic  characteristics,  they  will  be 
presented  in  groups  as  follows: 

Splenectomy,  April  6,  1904-June  9,  1915 

1.  Splenic   anemia    (pathologically   diffuse  fibrosis) 27  cases 

2.  Gaucher's   disease    (endothelioid    hyperplasia) 3  casesf 

3.  Pernicious    anemia    7  cases 

4.  Hemolytic    anemia    (marked    splenomegaly) 2  cases 

5.  Secondary    infectious    or    septic    splenomegaly 5  cases 

6.  L,ues    (marked    splenomegaly ) 2  cases 

7.  Acquired    hemolytic    (hematohepatogenous)    jaundice.  2  cases 

8.  Cirrhosis   of   liver    1  case 

9.  Myelocytic    leukemia    1  case 

10.   Lymphoma     or    lymphosarcoma 3  cases 

]  1.   Tuberculosis  of  spleen   1  case 

12.  Wandering    spleen     2   cases 

13.  Acute    febrile    nonseptic?    splenomegaly 1   case 

14.  Splenomegaly    with    marked    eosinophilia 1   case 

Total 58  cases 

Splenic  Anemia. — In  this  group  have  been  "placed  the  27  patients  in  whom 
the  enlargement  of  the  spleen  was  very  great  and  in  whom  splenomeg- 
aly seemed  to  be  the  primary  condition.  The  development  of  a  severe 
type  of  anemia  with  low  color  index  and  the  absence  of  leukocytosis 
were  regarded  as  essential.  Hematemesis  occurred  in  a  majority  of 
the  cases.  Pathologically  all  the  spleens  showed  an  increase  of  con- 
nective tissue.  There  were  3  operative  deaths  in  the  group,  while  the 
total  number  of  deaths  was  8  in  ten  years.  Hemorrhage  was  the  cause 
of  death  in  2  instances,  in  1  case  occurring  one  year  after  operation 
and  in  the  other,  five  and  one-half  years.  In  3  other  instances  hemor- 
rhage occurred  2  and  3  times  at  different  periods  after  operation,  but 
the  patients  are  at  present  in  good  health.  It  is,  therefore,  evident 
that  the  patients  in  this  group  had  a  low  operative  risk  and  an  ex- 
cellent  prospect   of    cure. 

Gaucher's  Disease. — Our  3  cases  in  which  the  spleen  showed  evidence  of 
endothelioid  hyperplasia  occurred  early  in  the  series.  We  have  been 
unable  to  obtain  a  history  of  familial  tendency  in  any  of  them.  One 
of  these  patients  is  in  excellent  health  seven  years  following  operation. 
In  2  patients  the  spleen  had  probably  been  enlarged  since  adolescence. 
Pernicious  Anemia. — Seven  patients  with  pernicious  anemia  have  been 
operated  on  in  our  clinic  since  August,  1914,  with  one  operative  death. 

*Abstracted   from   Ann.    Surg.,  Aug..    1915. 

tTwo  of  these  cases  have  been  questioned.     A  more  detailed  report  will  be  published 
later. 


272  TROPICAL    SURGERY   AND    DISEASES 

A  second  patient  died  two  months  after  operation  with  severe  anemia. 
The  third  patient,  two  and  one-half  months  after  operation,  is  in  very- 
good  health  with  hemoglobin  at  70  per  cent.  In  the  fourth  patient 
the  condition  of  the  blood  rapidly  improved  after  the  operation  and 
the  hemoglobin  was  75  per  cent  in  three  months.  The  fifth  patient, 
nine  months  after  operation,  has  gained  23  pounds,  the  hemoglobin 
is  70  per  cent  and  the  red  blood  count  3,026,000.  The  last  2  patients  are 
at  present  in  the  hospital.  It  is,  therefore,  seen  that  in  our  small  series 
of  splenectomies  for  pernicious  anemia  there  was  1  operative  death, 
1  death  at  two  months,  while  3  of  the  patients  showed  marked  tem- 
porary improvement.  Many  patients  with  pernicious  anemia  have 
presented  themselves  for  diagnosis,  but  we  have  hesitated  to  advise 
surgical  treatment. 

Hemolytic  Anemia  with  Very  Much  Enlarged  Spleen. — There  were  two 
cases  of  an  unusual  type  in  which  the  anemia  was  severe  in  character 
but  in  which  the  typical  count  of  true  pernicious  anemia  was  not  pres- 
ent and  in  which  the  spleen  was  very  much  larger  than  that  ordi- 
narily seen  in  pernicious  anemia.  The  first  patient  (A-7040)  was  op- 
erated on  February  10,  1910.  The  blood  count  showed  a  rather  high 
color  index,  not,  however,  above  1,  and  there  were  a  few  normoblasts 
and  megaloblasts  in  the  smears.  The  spleen  was  very  large,  weigh- 
ing 1640  grams.  After  operation  showers  of  normoblasts  occurred, 
a  finding  which  is  quite  unusual  in  other  types  of  splenomegaly  save 
that  of  pernicious  anemia.  The  second  patient  was  operated  on  Jan- 
uary 23,  1915.  The  spleen  was  enlarged  early  in  the  history  of  the 
disease,  apparently  before  the  development  of  anemia,  the  blood  find- 
ings were  similar  to  those  of  the  first  patient  and  the  spleen  was  large, 
weighing  1120  grams. 

It  is  true  that  these  2  cases  may  in  reality  be  pernicious  anemia, 
but  the  great  size  of  the  spleen,  the  fact  that  at  no  time  was  the  blood 
typical  of  pernicious  anemia,  and  the  further  observation  that  the  en- 
largement of  the  spleen  occurred  early  in  the  disease,  would  rather  lead 
to  the  conclusion  that  they  belong  to  a  separate  group  in  the  produc- 
tion of  which  a  disturbance  of  splenic  function  may  have  been  primary 
and  in  which  the  reaction  of  the  bone  marrow  was  different  from  that 
in  splenic  anemia. 

Secondary  Infections  or  Septic  Splenomegaly. — Under  this  heading  have 
been  placed  5  cases  in  which  the  enlargement  of  the  spleen  was 
not  marked,  in  which  the  splenomegaly  did  not  seem  to  be  a  primary 
factor  in  the  production  of  anemia  and  in  which  there  was  evidence  of 
preceding  abdominal  or  systemic  sepsis.  One  of  these  f)atients  is  in 
good   health   five   years   following   operation. 

Lues  ivith  Splenomegaly. — There  were  two  instances  in  which  large  non- 
gummatous  spleens  together  with  secondary  types  of  anemia  were  pres- 
ent in  patients  with  strong  positive  Wassermann  reactions.  In  one 
of  these  the  liver  was  smooth  and  specific  treatment  had  been  given 
elsewhere   without   benefit.      Splenectomy   was   followed   by   marked   im- 


;    '    APPEXDTX  273 

provoniifiit.  In  the  oflicr  inslance;  larfjo  palpable  guiiiniata  wore  pres- 
ent in  the  liver.  These  ^vere.very  mucli  reduced  by  specific  treat- 
ment before  operation  but  the  size  of  the  spleen  and  the  degree  of 
anemia  were  not  affected.  In  this  case  improvement  has  also  been 
marked  since  splenectomy. 

Acquired  Tlemolytic' (nenmtohepatogenaus)  Jaundice.^ — Two  cases  have 
been-  classified  as  hemolytic  jaundice.  It  is  possible  that  both  of  them 
might  also  be  regarded  as  advanced  forms  of  cholangitis  with  cirrhosis 
of  the  liver.  The  chronic  jaundice,  however,  was  prominent  in  these 
patients  and  the   anemia  was  marked. 

Cirrhosis  of  tJie  Liver. — One  case  has  been  regarded  as  cirrhosis  of  the 
liver.  In  this  patient  neither  was  the  spleen  large,  nor  the  anemia 
marked.     Advanced  cirrhosis,  of  the  liver  was  found  at  operation. 

Myelocytic  Leuhemia.—r'A  patient  classified  in -our  report  of  191.3  as  a 
case  of  splenic  anemia  and  so  regarded  by  careful  observers  in  other 
clinics,  but  of  whom  it  wa^  noted  at  the  timp.that  the  blood  picture 
was  not  entirely  satisfactory  for  this  grouping,  continued  to  be  in 
fairly  good  health  for  five  and  one-half  years,  after  which  the  leukocyte 
count  become  increased  to  64,000  with  14  per  cent  of  myelocytes. 

Lymphoma  or  Lymphosarcoma. — Our  series  includes  2  cases  of  lympho- 
sarcoma of  the  spleen.  One  of  the  patients  remained  -n^ell  for  sevdral 
years,  but  finally  died  with  generalized  sarcomatosis  nine  years  after 
operation.  The  second  patient  was  operated  on  July  3,  1914,  at  which 
time  there  was  no  evidence  of  metastases.  After  operation,  however, 
general  glandular  enlargement  rapidly  occurred  and  death  supervened 
five  months  latei*.  A  third  patient  presenting  a  decided  lymphocytic 
hyperplasia  pathologically  but  no  definite  evidence  of  malignancy  is  well 
eight  years  after  operation.     This  case  may  Be  benign. 

Tuieroulosis  of  the  Spleen. — In  1904,  a  large  spleen  which  proved  to  be 
tuberculous  was  removed  from  a  patient  who  at  the  time  of  operation 
gave  no  definite  evidence  of  tuberculosis  elsewhere  in  the  body. 

Wandering  Spleen. — Two  cases  of  this  type  were  operated  on  because  of 
pain  resulting  from  twisted  iJedicle.  These  patients  are  both  alive  and 
well  three  and  seven  years  following  operation. 

Acute  Feirile  Nonseptic  Splenomegahj. — Several  of  the  eases  in  this 
series  were  very  unusual  in  their  clinical  manifestations  and  in  the  com- 
bination of  conditions  present.  One  of  them  was  analogous  in  many 
ways  to  those  cases  occurring  in  Egypt  and  reported  as  Egyptian  spleno- 
megaly and  deserves  detailed  description. 

The  patient  was  a  man,  aged  thirty  years,  who  gave  a  history 
in  which  there  was  no  record  of  previous  disease.  He  had  seemed 
to  be  toxic  and  somewhat  stupid  for  6  or  8  weeks,  while  a  remit- 
tent fever  reaching  l03°  had  been  present.  There  had  been  ab- 
dominal enlargement  for  only  2  weeks,  but  no  history  of  hema- 
temesis,  while  ascites  was  present  at  the  time  of  examination  and 
the  spleen  could  be  felt  on  ballottemenf.    AVassermann  test,  Widal 


274  TROPICAL  SURGERY  AND  DISEASES 

reaction,  blood  cultures,  etc.,  were  negative.  In  spite  of  the  his- 
tory of  fever  and  the  acute  course  of  the  disease,  there  was  no 
leukocytosis  but  a  definite  leukoj)enia  with  a  relative  increase  of 
lymphocytes  and  an  anemia  of  the  secondary  type  with  hemoglobin 
at  70  per  cent.  The  patient  remained  under  observation  for  3 
months,  the  condition  became  less  acute  in  character,  and  sple- 
nectomy was  finally  decided  on.  The  spleen  was  very  large, 
weighing  1940  grams,  and  the  liver  was  somewhat  cirrhotic. 
(The  patient  remained  weak  after  operation,  had  3  hemorrhages 
from  the  bowels,  and  finally  died  5  months  following  operation.) 
The  acute  course,  the  presence  of  high  fever,  the  rapid  develop- 
ment of  a  very  large  spleen  and  ascites,  the  absence  of  leuko- 
cytosis and  other  evidence  of  sepsis  and  the  absence  of  jaundice 
formulate   the   picture   of   a   most  unusual   type    of   splenomegaly. 

Splenomegaly  with  MarTced  EosinopMlia. — As  far  as  we  have  been  able 
to  determine  there  is  no  case  of  this  type  to  be  found  in  the  literature. 

This  patient  was  a  man,  aged  thirty-one  years.  He  was  first 
seen  in  our  Clinic  in  March,  1913.  He  had  had  a  continued  fever 
which  was  diagnosed  as  typhoid  eight  years  previous,  and  had 
complained  of  weakness  since  that  time.  Transitory  edema  had 
been  present  for  ten  months  and  had  become  extreme  within  ten 
days.  At  the  time  of  his  first  visit  there  was  a  general  anasarca, 
on  account  of  which  he  was  j^laced  on  milk  diet,  and  the  edema 
disappeared  in  ten  days.  The  blood  count  at  the  time  showed 
a  secondary  type  of  anemia  with  hemoglobin  at  69  per  cent  and 
a  leukocyte  count  of  15,400,  while  the  most  remarkable  feature 
was  the  presence  of  a  66  per  cent  eosinophilia.  The  patient 
was  under  observation  for  three  months,  during  which  time  many 
blood  counts  were  made  and  verified  by  experienced  hematologists 
and  the  eosinophiles  varied  from  58  to  77  per  cent.  Wassermann 
tests  were  negative;  stools  were  negative;  and  the  examination 
of  muscle  for  trichinae  was  also  negative,  although  not  entirely 
satisfactory.  The  great  enlargement  of  the  spleen  persisted  and 
operation  was  finally  decided  on  and  performed  in  July,  1914. 
The  spleen  weighed  2110  grams.  The  patient  has  done  well  since 
the  operation;  his  leukocyte  count,  however,  has  risen  to  138,000, 
of  which  from  75  to  80  per  cent  are  eosinophiles.  There  is  very 
little  basis  for  speculation  at  to  the  possible  etiology  of  this 
unique   case. 

Eesume. — Our  series  of  58  cases  includes  27  of  splenic  anemia,  3  of  the 
Gaucher  type  of  splenic  anemia,  7  of  pernicious  anemia,  2  of  hemolytic 
jaundice,  5  of  secondary  infectious  or  septic  splenomegaly,  2  of  an 
unclassified  type  of  hemolytic  anemia  with  marked  splenomegaly,  2  of 
lues,  3  of  sarcoma  or  lymphoma,  2  wandering  spleens  and  1  each  of 
myelocytic  leukemia,  cirrhosis  of  the  liver  and  tuberculosis  of  the  spleen. 
In  addition,  it  includes  1  case  of  acute  febrile  nonseptie  splenomegaly 


APPENDIX  275 

which,  is  analogous  in  its  clinical  course  to  Egyptian  splenomegaly,  and 
1  case  in  which  splenomegaly  was  associated  with  an  extremely  high 
eosinophilic  count.  Splenic  anemia  is,  in  our  experience,  most  favor- 
able for  surgical  treatment.  The  operative  risk  is  relatively  low  and 
the  prospect  for  a  return  to  normal  health  excellent.  Three  of  the  7 
patients  with  pernicious  anemia  have  shown  temporary  improvement 
up  to  9  months  after  splenectomy.  Eemoval  of  the  spleen  in  non- 
gummatous  splenomegaly  associated  with  syphilis  has  been  attended  with 
excellent  results  in  two  instances. 

Pathology  of  Spleens  Removed  for  Certain  Abnormal  Conditions  of 
the  Blood  (Louis  B.  Wilson,  Mayo  Clinic)." — This  study  is  a  continuation 
of  a  previous  report^  which  covered  the  pathologic  examination  of  26 
spleens  removed  at  operation  or  autopsy  in  the  Mayo  Clinic,  between  No- 
vember 14,  1905,  and  November  1,  1912,  from  patients -on  18  of  whom  a 
more  or  less  positive  clinical  diagnosis  of  splenic  anemia  had  been  made, 
and  of  two  "wandering  spleens"  removed  at  operation  within  the  same 
period,  and  of  31  more  spleens  removed  at  operation,  between  December 
3,  1912,  and  June  9,  1915.  Giffiu's^  grouiDing  is  observed  in  the  fol- 
lowing pathologic  protocols: 

Summary  of  Protocols  of  Group  1 — Splenic  Anemia. — It  will  be  seen 
from  the  above  proctocols  that  the  average  age  of  the  patients  with 
a  blood  picture  of  splenic  anemia  at  the  time  of  operation  was  thirty- 
six  years.  The  average  duration  of  symptoms  was  32  months.  The 
average  weight  of  the  spleen  was  1130  grams.  This  is  a  little  higher 
than  the  average  weight  (10-40  grams)  of  the  spleens  from  our  positive 
splenic  anemia  (revised  clinical  classification)  cases  reported  in  1913. 
The  average  of  the  two  groups  is  1093  grams.  Few  of  the  specimens 
equal  the  weights  given  by  Lyon,3  who  states  that  the  average  weight 
is  62  ounces  (1860  grams).  This  discrepancy  is  probably  due  to  the 
fact  that  Lyon's  figures  are  drawn  largely  from  autopsy  reports,  while 
ours  are  from  operative  material,  the  spleen  continuing  to  enlarge  until 
death.  In  general  the  change  in  the  shape  of  the  si^leen  is  not  so  marked 
as  the  change  in  size.  In  other  words,  the  hypertrophy  is  evenly  diffuse 
except  in  those  cases  in  which  infarcts  have  occurred.  The  maintenance 
of  the  notch  is  important  from  the  standpoint  of  clinical  diagnosis. 

Histologically,  the  most  constant  features  are  the  marked  reduction 
of  the  pulp  and  lymphoid  tissue  with  the  great  increase  of  reticulum 
and  the  almost  constant  presence  of  amyloid  degeneration  and  arterio- 
sclerosis. Whether  the  diffuse  hypertrophic  fibrosis  is  the  result  of 
inflammatory  changes  has  not  been  accurately  determined.  I  see  no 
reason  at  present,  however,  to  change  from  the  commonly  accepted 
theory  that  the  process  is  one  of  low  grade  chronic  inflammation.  In 
this  connection  it  may  be  noted  that  Bunting  has  isolated  a  diphtheroid 
organism  in  pure  culture  in  four  out  of  twelve  tubes  shown  from  the 
spleen  in  our  Case  XII. 


*Abstracted  from  Ann.   Surg.,  Aug.,  1915. 


276  TEOPICAL    SURGEr.Y    AND   DISEASES 

Summary  of  Protocols  of  Group  2 — Acquired  Pernicious  Anemia. — 
The  average  age  of  patients  with  pernicious  anemia  was  forty-four 
years  at  the  time  of  operation.  The  average  duration  of  symptoms  was 
27  months.  The  average  weight  of  the  spleens  removed  was  463  grams. 
Only  one  was  less  than  normal  (195  grams). 4  The  increase  in  weight 
is  out  of  harmony  with  our  conception  of  the  atrophy  usually  found 
in  the  spleen  in  cases  of  pernicious  anemia.s  Here  again  the  dis- 
crepancy is  probably  accounted  for  by  the  fact  that  in  the  last  stages 
of  pernicious  anemia  the  spleen  becomes  atrophic,  while  our  figures, 
based  on  operative   cases,  show   an  increased  weight   of  the   organ. 

Cytologically  the  increase  is  mostly  in  the  lymphoid  tissue,  though 
it  is  worthy  of  note  that  in  one  case  (Case  III)  there  was  a  well  marked 
fibrosis,  this  spleen  weighing  almost  twice  the  average  weight  of  the 
glands  in  the  series.  The  almost  entire  absence  of  pigment  in  these 
relatively  early  sta,ge  cases  is  again  in  contradiction  to  the  usually 
accepted  statement  that  in  cases  of  pernicious  anemia  the  spleen  is  pig- 
mented. 

General  Summary  of  the  Last  Seven  Groups. — The  cases  of  hemolytic 
anemia,  lues,  and  hemolytic  jaundice  resemble  pathologically  the  cases 
of  splenic  anemia.  The  cases  of  secondary  infection,  lymphosarcoma, 
acute  febrile  nonseptic  sj^lenomegaly,  and  splenomegaly  with  eosinophilia 
have  little  pathologic  relationship  to  either  splenic  anemia  or  pernicious 
anemia.  The  lymphosarcoma  case  is  a  typical  lymphoma  whose  malig- 
nancy was  shown  clinically.  The  other  three  cases  give  the  general 
picture  of  an  intense  acute  or  subacute  infection,  causing  hypertrophy 
and  hyperplasia  of  all  the  parenchymal  elements  of  the  spleen  without 
material  increase  in  the  reticulum. 

Our  knowledge  of  the  pathology  of  splenomegaly  associated  with 
chronic  changes  in  the  blood  has  made  slow  progress,  largely  because — • 
except  in  rare  instances — ^we  have  been  unable  to  study  spleens  from 
such  cases  until  the  later  or  terminal  stage  of  the  diseases  has  Ijeen 
reached.  Now  that  splenectomies  are  becoming  more  common,  it  is 
fair  to  assume  that  clinicians  will  be  on  the  lookout  for  large  spleens 
in  all  cases  of  pathologic  conditions  of  the  blood  and  that  we  may  hope 
for  opportunity  to  study  early  pathologic  changes  in  the  glands  removed 
at  operation.  If  any  progress  is  to  be  made,  however,  we  must  sharply 
differentiate  the  relative  changes  in  the  various  histologic  elements  of 
the  spleen  and  these  changes  must  be  studied  in  coiTelation  with  accu- 
rately observed  clinical  phenomena.  At  present  the  clinical  diagnoses 
of  splenic  anemia,  pernicious  anemia,  secondary  infectious  anemia, 
hemolytic  jaundice,  Gaucher 's  disease,  etc.,  are  all  lacking  in  clearness, 
a  condition  which  must  be  materially  improved  upon  before  an  instruc- 
tive parallel  may  be  shown — if,  indeed,  any  exist — between  the  several 
clinical  syndromes  in  their  various  stages  and  the  pathologic  picture 
present  in  the  spleen. 


APPENDIX  277 

BIBLIOGRAPHY 

^Wilson,  L,.  B. :  The  Pathology  of  Splenomegaly,  Surg.,  Gynec,  Obst.,  1913,  xvi,  240- 
252. 

-Giffin,  H.  Z.:     Clinical  Notes  on  Splenectomy,  Ann.  Surg.,  Ixii,  August,  1915. 

'I^yon,  I.  P.:  Diseases  of  the  Spleen,  Osier  and  McCrae  Modern  Medicine,  1915,  iv, 
957. 

■■Piersol,  George  A.:     Practical  Anatomy,  ii,  1871. 

^Cabot,  Richard  C. :  Pernicious  and  Secondary  Anemia,  etc..  Osier  and  McCrae  Mod- 
ern Medicine,   1915,  iv,   626. 

Discussion  of  Splenectomy  for  Splenic  Anemia  in  Childhood  (H.  Z. 
Giffin,  Mayo  Clinic). — An  excellent  conception  of  the  varied  types  of  dis- 
ea.se  in  which  anemia  is  associated  with  chronic  enlargement  of  the  spleen 
in  children  and  infants  can  be  obtained  from  the  several  papers  by  Went- 
worth,  in  which  are  given  excellent  reviews  of  reported  cases.  Wentworth 
concludes  that  the  splenic  anemia  of  infancy  is  a  secondary  anemia 
and  in  no  way  related  to  leukemia.  He  also  infers  that  the  adult 
form  of  splenic  anemia  may  be  a  prototype  of  the  splenic  anemia  of 
infants.  Hutchison  collected  22  cases  of  the  splenic  anemia  of  in- 
fancy in  patients  from  9  months  to  21^  years  of  age.  Ostrowsky  re- 
ports 10  cases  of  his  own,  varying  in  age  from  7  months  to  2  years 
with  leukocyte  counts  of  from  8,000  to  25,000.  Carpenter  in  a  review 
of  348  patients  with  splenomegaly,  under  12  years  of  age,  places  rickets 
first  and  syphilis  second  in  the  etiological  role.  Ashby  concludes  that 
the  toxin  causing  rickets  may  also  cause  the  splenic  anemia  of  in- 
fancy and  that  the  reported  cases  vary'  from  those  with  marked  bone 
changes  and  small  spleen  to  those  with  slight  bone  changes  and  a 
very  large  spleen.  Carr  draws  attention,  however,  to  the  following 
facts:  First,  that  in  a  majority  of  rickety  children  there  is  no  splenic 
enlargement;  second,  that  there  is  no  connection  between  the  severity 
of  the  rickets  and  the  size  of  the  spleen  or  the  degree  of  the  anemia; 
third,  that  in  certain  cases  of  the  splenic  anemia  of  infancy  there  is 
no  evidence,  whatever,  of  rickets.  The  general  experience  seems  to 
indicate  that,  granted  the  frequent  association  of  rickets,  there  are  yet 
certain  cases  which,  on  account  of  their  marked  splenomegaly  and  their 
severe  anemia,  their  evidences  of  extensive  blood  destruction,  and  a 
reversion  to  the  fetal  type  of  hemopoiesis  should^  for  the  present  at 
least,  be  grouped  together  as  a  separate  disease  entity. 

Reports  of  cases  of  the  adult  form  of  splenic  anemia  occurring  in 
children  under  2  years  of  age  are  very  difficult  to  find,  while  the  splenic 
anemia  of  infancy  seems  practically  never  to  be  present  in  patients 
over  the  age  of  2J/4  years.  This  observation  is  in  itself  suggestive  of 
the  possibility  that  some  relationship  may  exist  between  the  two  dis- 
eases. The  chief  clinical  distinctions  between  the  adult  form  of  splenic 
anemia  and  the  splenic  anemia  of  infancy  are  in  the  blood  picture,  and 
chiefly  the  characteristics  of  the  leukocyte  count.  In  the  splenic  ane- 
mia of  infancy  there  is  more  evidence  of  blood  destruction  than  in  the 
splenic  anemia  of  adults;  the  red  cell  count  is  likely  to  be  lower  and 
the  color  index  consequently  higher,  and  normoblasts  and  megaloblasts 


278  TEOPICAL    SUEGEEY   AXD    DISEASES 

are  present  in  tlie  blood  smears.  In  the  adult  form  of  splenic  anemia 
there  is  an  absence  of  leukocytosis  while  in  the  splenic  anemia  of 
infancy  there  is  a  notable  leukocytosis,  which  is,  however,  in.  reality 
a  lymphocytosis.  Our  knowledge  concerning  the  normal  blood  of  in- 
fants and  the  reaction  of  the  infant's  blood  to  various  toxic  agents 
would  lead  us  to  regard  these  differences  as  less  surprising.  And  espe- 
cially does  the  biological  fact  that  infancy  is  a  transition  period,  in 
which  there  may  be  reversions  to  the  fetal  type  of  hemoj)oiesis,  have 
a  bearing  upon  the  variations  in  the  infantile  type  of  splenic  anemia.  In 
addition  to  the  above  characteristics,  we  now  have  also  the  knowledge 
that  splenectomy  has  been  followed  by  excellent  results  in  both  con- 
ditions. These  facts  would  suggest  the  possibility  that  the  splenic 
anemia  of  infancy  may  be  a  similar  condition  to  the  splenic  anemia  of 
adults  and  that  the  differences  may  be  largely  due  to  the  peculiar  reac- 
tion of  the  infants'  hemopoietic  system  to  the  etiologic  factor  in  the  dis- 
ease. For  the  present,  and  until  our  knowledge  is  much  fuller,  a  sharp 
distinction  should  be  drawn  between  the  two  conditions. 

SUIIMAEY 

1.  The  normal  lymphocytosis  of  the  infants'  blood  and  its  decided 
reaction  to  various  toxic  agents  is  always  to  be  taken  into  account  in 
consideration  of  any  ease  of  infantile  anemia.  Infancy  is  a  transition 
period  during  which  a  reversion  to  the  fetal  type  of  hemopoiesis  is  likely 
to  occur. 

2.  The  adult  form  of  splenic  anemia  as  it  occurs  in  children  and  the 
splenic  anemia  of  infancy  have  many  characteristics  in  common,  and  also 
certain   distinctive   differences. 

3.  There  is  sufficient  evidence  to  indicate  a  close  relationship  between 
the  adult  form  of  splenic  anemia  as  it  occurs  in  childhood  and  the  splenic 
anemia  of  infancy.  Until  our  knowledge  is  fuller,  however,  a  shai-p  dis- 
tinction should  be  drawn  between  the  two  diseases. 

4.  Splenectomy  has  been  performed  in  only  a  few  instances  of  the 
adult  form  of  splenic  anemia  occurring  in  the  first  decade  of  life.  One 
case  of  this  character  is  reported  herewith.  There  is  a  doubt  as  to  the 
exact  diagnosis  in  some  of  the  seven  cases  collected  from  the  literature. 

5.  A  review  of  the  literature  of  the  splenic  anemia  of  infancy  (anemia 
pseudoleukemica  of  von  Jaksch)  shows  that  splenectomy  has  been  per- 
formed in  4  instances  of  severe  types  of  the  disease,  with  marked  im- 
mediate improvement. 

The  Diagnosis  of  Diseases  Associated  with  Enlargement  of  the  Spleen 
(H.  Z.  Giffin,  Mayo  Clinic). — Exannuation  uf  the  liver  and  spleen  at  the 
time  of  operation  lias  stimulated  the  interest  of  the  surgeon  in  diseases 
which  have  been  hitherto  regarded  as  entirely  medical.  This  interest  will 
result  in  additions  to  our  knowledge  of  the  relative  functions  of  the  organs 
of  the  upper  abdomen  and  will  eventually  assist  in  making  the  classifi- 
cation of  hepatic  and  splenic  diseases  more  nearly  definite.  That  one 
may  be  in  the  receptive  mood  it  is  necessary  to  become  as  familiar  as  is 
possible  with  the  diagnosis  of  diseases  associated  with  si^lenomegaly. 


APPEXDIX  279 

The  exact  degree  of  enlargement  of  the  spleen  is  usually  not  fleter- 
mined  until  an  edge  is  palpable  belovr  the  costal  margin.  The  fact  that 
the  outline  of  the  spleen  by  percussion  is  uncertain  because  of  its^  sit- 
uation is  not  an  excuse,  however,  for  the  more  or  less  general  careless- 
ness exhibited  in  examining  for  the  size  of  the  spleen  as  a  matter  of 
routine.  The  spleen  may  lie  high  and  be  enlarged  transversely,  and  in 
this  event  a  definite  splenomegaly  may  be  overlooked.  Perisplenitis, 
is  a  frequent  surgical  and  x>athologic  finding,  and  it  is  quite  likely  that 
clinical  evidence  of  this  condition  is  not  obtained  as  often  as  it  should 
be. 

If  a  patient  Tvith  a  palpable  enlargement  in  the  region  of  the  spleen 
presents  himself  for  examination,  it  is  of  course  first  essential  to  de- 
termine positively  whether  or  not  the  organ  be  spleen.  And  tMs  dis- 
tinction is  not  always  easy.  The  question  will  usually  lie  between 
spleen  and  kidney.  If  one  can  feel  edge  and  notch,  there  is  no  difficulty, 
but  it  is  sometimes  impossible  to  demonstrate  the  characteristic  contour. 
The  edge  of  the  spleen,  like  the  edge  of  the  liver,  may  at  times  be 
revealed  by  pressing  the  mass  forward  and  toward  the  median  line  at 
the  same  time  everting  the  anterior  portion.  Similarly,  the  organ  may 
be  pressed  into  the  loin  and  its  edge  everted.  Often  the  Mdney  may  be 
demonstrated  as  a  separate  mass  lying  posteriorly.  By  these  means 
a  difficult  diagnosis  may  be  made  simple.  At  times,  however,  the  only 
certain  method  of  arri\-ing  at  a  conclusion  is  by  means  of  eystoscopic 
and  pyelographic  examination.  The  development  of  pyelography  assures 
reasonably  accurate  information  as  to  the  existence  of  a  tumor  of  the 
kidney,  and  pyonepkrosis,  hypemephromaj,  and  cystic  kidney  have  so 
resembled  the  spleen  as  to  make  a  diagnosis  impossible  without  this 
procedure,  and  perfectly  definite  with  it.  Tke  position  of  the  kidney 
as  demonstrated  by  the  injection  of  colloidal  silver  may  be  compared 
with  the  position  of  the  tumor  at  the  time  of  exposure,  taking  into 
consideration  the  focus  used  in  making  the  radiogram. 

MovaMe  and  wandenng  spleens  are  occasionally  seen  and,  upon  super- 
ficial examination,  may  be  diagnosed  as  movable  kidney.  The  spleen 
may  descend  as  low  as  the  pelvis.  If,  however,  the  occurrence  of  wan- 
dering spleen  be  kept  in  mind,  the  organ  usually  can  be  recognized  by 
its  contour.  Two  cases  of  wandering  spleen  have  been  operated  on  at 
St.  Mary's  Hospital.  Another  patient  had  been  operated  on  elsewhere 
for  movable  kidney  apparently  as  the  result  of  a  mistaken  diagnosis. 
The  Iddney  had  been  stitched  up,  but  the  tumor,  which,  upon  palpation, 
showed  all  the  characteristics  of  spleen,  remained  as  movable  as  before. 

Upon  first  consideration  it  would  appear  that  tumors,  of  the  stomach 
and  intestine  could  not  be  confusing  in  the  diagnosis  of  splenomegaly. 
During  the  last  year,  however,  the  writer  has  observed  two  cases  in 
which  a  large  carcinomatous  mass  could  not  be  differentiated  from  en- 
largement of  the  spleen  before  operation.  The  absence  of  a  history  of 
gastric  symptoms,  negative  findings  on  gastric  analysis,  the  demonstration 
of  an  edge,  and  the  location  of  the  tumor  led  us  to  regard  the  tumor 


280  TROPICAL    SURGERY   A2^D   DISEASES 

as  most  likelv  spleen,  altliougiL  tlie  coutour  was  not  typical  enough,  to 
warrant  a  positive  diagnosis.  One  of  these  cases  had  been  diagnosed 
previously  as  splenic  anemia  by  an  internist  of  great  experience.  An 
intestinal  tumor  will  more  often  simulate  the  kidney  than  the  spleen. 
The  left  lobe  of  the  liver  may  be  enlarged  in  such  a  way  that  its 
edge  descends  at  the  left  costal  border  and  is  thus  confusing.  Omental 
tumors  must  be  differentiated  from  movable  spleen.  If  the  splenic  dull- 
ness can  be  definitely  outlined  by  percussion,  a  diagnosis  may  be  made 
by  exclusion. 

The  spleen  may  be  moderately  enlarged  for  years  without  apparent 
injury  to  health.  Osleri  reports  having  seen  a  group  of  such  cases  in 
women  without  anemia  and  from  no  evident  cause.  On  several  occasions 
we  have  observed  in  Greeks  a  moderate  enlargement  of  the  spleen 
without  complaint  or  indicative  findings.  Some  of  these  doubtless  had 
had  malaria.  Cabofs  has  noted  tliat  other  peojjles  from  Southern.  Europe 
present  the  same  condition. 

While  a  slight  enlargement  of  the  spleen  seems  to  occur  without 
harm,  it  must  also  be  remembered  that  splenic  enlargement  sometimes 
precedes  the  development  of  anemia  by  several  years'  splenic  anemia, 
and  the  spleen  must  be  looked  upon  as  a  possible  source  of  future 
trouble,  especially  if  it  be  of  considerable  size.  Its  removal  may  then 
be  considered. 

The  spleen  may  be  temporarily  enlarged  in  many  of  the  acute  infections 
of  childhood,  also  in  rickets  and  other  forms  of  malnutrition  in  babes.  The 
enlargement  of  the  spleen  which  occurs  with  typhoid  fever,  generalised  tu- 
berculosis, and  malaria,  need  only  be  mentioned.  In  connection  with  tuber- 
culosis it  must  not  be  forgotten  that  a  marked  tuberculous  enlargement 
of  tlie  spleen  inay  occur  without  evidence  of  tuberculosis  elsewhere. 
In  some  of  the  reported  spleens,  however,  the  tuberculous  process  seems 
to  be  less  prominent  than  the  general  hyperplasia.  One  patient  of  this 
type  was  operated  upon  at  St.  Mary's  Hospital  in  1904  and  made  a 
good  recovery,  but  died  four  months  later.  Franke3  has  collected  ten 
such  operative  cases.  It  is  not  likely  that  this  type  of  splenomegaly 
will  be  differentiated  from  splenic  anemia  unless  tuberculosis  can  be 
demonstrated  elsewhere  in  the  body.  The  spleen  of  malaria  has  been 
removed  when  other  treatment  has  failed  to  prevent  the  return  of  at- 
tacks. The  diagnosis  is  usually  made  easily;  in  fact,  there  is  a  temp- 
tation to  ascribe  splenic  hypertroj)hy  to  inalaria  when  it  may  have  no 
etiologic  relationship. 

Syphilid  of  the  spleen  should  always  be  considered  as  a  possibility  in 
every  patient  with  splenomegaly,  and  a  "Wassermann  reaction  can  not 
be  neglected  in  any  questionable  case.  The  frequency  of  syphilis  seems 
to  be  quite  generally  appreciated  at  the  present' time  so  that  this  error 
is  less  likely  to  occur  today  than  it  was  ten  years  ago.  Syphilitic 
cirrhosis  of  the  liver  v.ith  splenomegaly  is  of  comparatively  frequent 
occurrence,  and  the  difficulty  of  obtaining  a  history  of  infection  is 
notorious.       Congenital   syphilis    of   the   spleen    is   not  -rare,  in   children. 


APPENDIX  281 

There  is,  however,  a  nonluetic  cirrhosis  of  the  liver,  which  oer-urs  in 
children;    ascites  and  moderate   enlargement   of  the   spleen   are  present. 

Frimary  sarcoma  of  the  spleen  is  rare;  the  growth  of  the  organ  is  rapid. 
Twenty-five  cases  have  been  reported  and  are  reviewed  in  a  paper  by 
Bush.4  Eleven  of  the  25  were  discovered  at  autopsy,  while  in  14  sple- 
nectomy w^as  done  with  four  operative  deaths.  Two  remained  well 
for  several  years.  Pathologists  agree  that  a  positive  diagnosis  of  sar- 
coma of  the  spleen  is  often  hazardoiis,  and  when  recurrence  does  not 
follow  there  is  a  possibility  that  the  tumor  was  in  reality  a  benign 
lymphoma.  (Tiirk;5  Sternberg.e)  One  patient  on  whom  splenectomy 
was  done  at  the  Mayo  Clinic  for  what  was  morphologically  lymphosar- 
coma has  remained  well  for  seven  years.  In  another  case  a  diagnosis 
of  lymphoma  was  made,  and  the  patient  has  remained  well  for  a  year 
and  one-half.  Clinically  these  two  cases  presented  the  syndrome  of 
splenic  anemia. 

The  Gaucher  type  of  endothelioma  of  the  spleen  is  regarded  by  some  ob- 
servers as  a  true  tumor.  Clinically,  however,  these  cases  may  not  be 
differentiated  from  splenic  anemia,  although  Brill7  has  suggested  cer- 
tain points  which  may  be  of  assistance  in  diagnosis.  Three  spleens  of 
this  type  have  been  removed  at  St.  Mary's  Hospital.  The  clinical  his- 
tories were  those  of  splenic  anemia. 

Cystic  spleen  may  be  difficult  to  differentiate  from  cystic  kidney  and 
cyst  of  the  pancreas.  Cyst  of  an  aberrant  duct  of  the  liver  in  the  left 
triangular  ligament  has  been  reported.  Cysts  occur  in  the  spleen  in 
about  there  per  cent  of  patients  with  hydatid  disease.  Of  nonparasitic 
cases,  42  instances  have  been  reported  (Mussers).  Fiiroma  of  the  spleen 
is  rare.  Carcinom,a  of  the  spleen  is  secondary  and  uncommon  in  occur- 
rence. Infarcts  in  arterial  disease  and  abscess  in  infectious  diseases  may 
cause  splenic  enlargement. 

Pernicious  anemi-a  may  be  associated  with  enlargement  of  the  spleen, 
and,  if  the  blood  findings  be  not  typical  at  the  time  of  examination,  a 
diagnosis  may  have  to  be  deferred.  The  spleen  is  usually  not  lar,ge, 
and  in  this  there  is  a  contrast  with  splenic  anemia  and  Banti's  disease. 
Occasionally  the  coexistence  of  a  very  large  spleen  and  an  atypical 
blood-count  leads  to  a  questionable  diagnosis. 

Lymphatic  and  myelogen&us  leulcemia  need  only  lie  mentioned  as  the 
blood  pictures  are  pathognomonic.  Care,  .however,  must  be  taken  if  leukemia 
be  seen  in  the  aleukemic  stage.  It  must  not  be  forgotten  that  an  enlarged 
spleen  accompanies  polycytliemia.  The  term  psendoJeitl:emia  is  indefinite 
and  should  probably  be  reserved  for  that  condition  in  which  lympho- 
cytic infiltration  of  the  viscera  occurs  without  the  characteristic  blood 
changes  of  lymphatic  leukemia.  There  is  a  low  leukocyte  count  with 
lymphocytic  increase,  enlargement  of  the  liver  and  spleen,  and  slight 
enlargement  of  the  lymjihatic  glands.  Tlie  nn<Toscoiuc  oxamiiiation  of  an 
excised  gland  shows  hyperplasia.  This  condition  often  occurs  in  chil- 
dren and  may  be  in  reality  some  one  of  the  other  forms  of  anemia  in 
w'hich  the  blood  picture  has  been  altered  by  reason  of  its  attack  upon 


282  TROPICAL    SURGERY   AXD    DISEASES 

a  youthful  rather  than,  an  adult  organism.  The  diagnosis  of  the  diseases 
of  the  blood  in  ehildi'en  is  very  uncertain  at  best.  Secondary  anemias 
occurring  with  rickets,  and  congenital  syphilis  may  give  blood  pictures 
suggestive  of  pernicious  anemia,  lymphatic  leukemia,  myelogenous  leu- 
kemia, or  splenic  anemia. 9  Consequently,  "when  an  abnormal  blood  pic- 
ture is  obtained  in  an  infant,  the  possibility  of  nutritional  disturbances 
must  first  of  all  be  considered. 

Splenic  anemm  seems  to  be  a  f  aiiiy  definite  clinical  entity,  although  many 
observers  prefer  to  look  upon  it  as  a  symptom  complex.  It  is  described 
as  a  disease  of  unknown  origin,  presenting  a  progressive  enlargement 
of  the  spleen:  a  chronic  course  of  from  months  to  ten  years  and  even 
twenty  years:  an  anemia  of  the  secondary  type,  generally  with  leu- 
kopenia; a  tendency  to  hemorrhage,  especially  to  hematemesis;  a  cer- 
tain degree  of  pigiaentation  in  the  late  stages:  and  a  secondary  cirrhosis 
of  the  liver  with  or  without  ascites.  The  histories  of  these  cases  seem 
to  indicate  that  the  splenic  change  is  primary.  Enlargement  of  the 
spleen  may  be  present  for  years  before  the  development  of  anemia. 
An  absence  of  leukocytosis  seems  to  be  an  almost  constant  fijiding. 
Leukocytosis,  save  after  hematemesis,  should,  therefore,  make  one  sus- 
picious of  some  condition  other  than  splenic  anemia.  The  spleen  is  often 
very  large,  and  in  this  it  differs  from  the  spleen  of  hepatic  cirrhosis. 
In  cirrhosis  the  liver-changes  seem  to  precede  the  splenic  enlargement, 
while  the  reverse  is  true  in  splenic  anemia.  In.  cirrhosis  again  the 
anemia  is  less  marked,  and  an  etiologie  factor  of  cirrhosis  may  be  pres- 
ent. Hanoi's  cirrJwsis,  presenting  a  moderately  enlarged  spleen,  oc- 
curring in  young  people  without  a  history  of  the  usual  causes  of  cir- 
rhotic liver  and  accompanied  by  a  chronic  jaundice,  should  not  be  dif- 
ficult of  differentiation.  In  Jiemochromatosis  the  changes  in  the  liver 
and  the  splenic  enlargement  are  concomitant,  and  the  deposition  of  iron 
pigment  in  the  skin  and  viscera  and,  later,  diabetes  as  a  result  of  in- 
volvement of  the  pancreas,  form  a  definite  clinical  picture.  Splenic 
enlargement  may  also  occur  in  Sodglcin's  disease.  In  late  Hodgkin's 
disease  the  splenic  and  hepatic  hypertrophy  may  be  prominent,  while 
the  size  of  the  lymphatic  glands  may  decrease  and  a  leukopenia  occur 
giving  a  clinical  picture  which  at  first  sight  may  suggest  splenic  ane- 
mia.1,0  The  history  of  the  early  involvement  of  a  group  of  glands,  how- 
ever, usually  points  the  way  to  a  diagnosis.  The  excision  and  micro- 
scopic examination  of  a  gland  will  often  give  positive  evidence.  In  the 
family  type  of  hemolytic  jaundice  with  splenomegaly  the  jaundice  may 
be  absent  temporarily,  and  the  condition  may  thus  be  confused  with 
splenic  anemia.n  Acute  infectious  epidemic  jaundice  (Weil's  disease) 
would  give  no  ditfieulty  because  of  its  clinically  acute  infectious  nature. 
As  previously  noted,  syphilis  of  the  spleen  must  always  be  kept  in  mind 
and  carefully  excluded. 

There  is  a  group  of  cases  simulating  the  clinical  picture  of  splenic 
anemia  and,  in  addition,  presenting  findings  suggestive  of  an  acute  or 
subacute  infectious  process.     The  fever  may  be  remittent  or  intermittent 


APPEXDIX  283 

and  aecompaniod  by  chills.  Attacks  may  last  two  or  three  months  at 
a  time  and  may  recur  at  intervals  of  several  months,  or  the  condition 
may  be  an  acute  one,  givin,g  a  history  of  several  months'  illness.  The 
.size  of  the  spleen  and  liver  may  be  much  reduced  between  attacks,  and 
the  patient  may  return  to  good  general  health.  Leukopenia  is  present  save 
at  the  time  of  chills  and  high  fever.  Blood  cultures  are  negative,  and  no 
evidence  of  s^'philis,  malaria,  or  tuberculosis  can  be  detected.  Two  cases 
with  these  characteristics  have  been  observed  by  the  writer.  Are  these 
acute  types  of  splenic  anemia,  or  is  the  clinical  course  the  result  of 
phlebitis  of  the  splenic  vein,  a  condition  which  has  been  reported  in 
the  autopsy  findings  in  certain  cases?  The  condition  may  indeed  be  due 
to  a  more  or  less  generalized  chronic  infectious  process.  In  view  of  the 
fact  that  kala-asar  with  its  enormous  enlargement  of  liver  and  spleen 
may  make  its  appearance  at  any  time,  it  is  imperative  in  cases  of  the 
foregoing  type  to  examine  the  peripheral  blood,  the  blood  obtained  by 
splenic  puncture,  or  an  excised  cervical  gland,  for  the  presence  of 
Leischman-Donovan  bodies. 

In  all,  27  splenectomies  have  been  done  at  the  Mayo  Clinic,  St.  Mary's 
Hospital,  from  April,  1904,  to  July,  1912.  Of  these  cases,  18  conformed 
most  nearly  to  the  group  commonly  regarded  from  a  clinical  standpoint 
as  splenic  anemia. 

A  review  of  the  diseases  associated  with  enlargement  of  the  spleen 
impresses  one  with  the  fact  that  exhaustive  examinations  and  complete 
notes  are  necessary  if  we  may  hope  to  arrive  at  a  definite  grouping  of 
these  obscure  conditions.  Pathologic  and  clinical  information  must  be 
carefully  correlated.  Certain  rare  disorders  must  be  kept  freshly  in 
mind.  Laboratory  findings  must  be  utilized  in  the  differentiation  more 
liberally  than  is  ordinarily  necessary.  One  is  repaid,  however,  by  the 
unusual  interest  attaching  to  these  diseases,  especially  to  those  that 
simulate  the  symptom  complex  of  splenic  anemia. 

KEFEREXCES 

^Osler:     Am.   Jour.  Med.    Sc,    1902,   cxiv,   751,   770. 

-Cabot:     Quoted  by  Osier.  Am.   Tour.   Med.   Sc,   1902,   cxiv,   751-770. 

^Franke:     Deutsch.    mad.    Wchnschr..   1906,   xxxii,    1656-1659. 

4Bush:     Jour.   Am.   Med.   Assn.,  liv,   1910,   453-456. 

^Turk:     Wien.  klin.   Wchnschr.,  xvi,  No.   39,   1903;   also,   1907,  Xo.   8. 

^Sternberg:     Lurbarsch   Ostertag,    1903,   II. 

•Brill:     Am.   Tour.   Med.   Sc,  cxxix,    1905,  491-504. 

sMusser:     Am.  Jour.   Med.    Sc.   1911,  cxlii,  S01-50S. 

"Shaw:      Lancet,   1904,   ii,   1560-1562. 
"Weber:     Am.  Tour.  Med.  Sc,  cxlii,  1911.  508-522. 
"Weber  and  Dorner:     Lancet,   1910,  i,  227-232. 

The  Relation  of  the  Spleen  to  Certain  Obscure  Clinical  Phenomena 
(William  J.  Mayo).* — Pernicimis  Anemia-. — We  have  removed  the  spleen 
fifty  times  foi-  pernicious  anemia.  In  each  case  the  diagnosis  was  well  estab- 
lished, and  the  spleen,  witli  four  exceptions,  was  above  normal  in  weight. 
In  some  instances  the  spleen  was  greatly  enlarged,  weighing  up  to  2.'>.30 
"rams. 


*Weslev  M.   Caroenter   Lecture,  New  York  Academv   of  ^Medicine,  New   York   City, 
Oct.    18,    1917. 


284  TROPICAL  SURGERY  AND  DISEASES 

There  has  been  no  definite  relation  between  the  size  of  the  spleen  and 
the  seriousness  of  the  disease,  nor  was  there  any  direct  relationship  between 
the  result  of  the  splenectomy  and  the  size  of  the  spleen  removed.  This  of 
itself  is  a  suspicious  circumstance.  The  benefit  derived  from  splenectomy, 
generally  speaking,  has  followed  the  removal  of  a  definitely  enlarged  spleen. 
The  failure  to  establish  such  relationship  in  pernicious  anemia,  or  to  connect 
with  the  disease  such  gross  and  microscopic  changes  as  are  to  be  found 
in  the  removed  spleens,  would  lead  us  to  expect  only  limited  benefit  rather 
than  cure  of  pernicious  anemia  through  si^lenectomy.  There  was  temporary 
improvement  in  every  case,  but  following  splenectomy  we  had  some  cases 
in  which  the  cord  changes  progressed  in  spite  of  a  great  improvement  in  the 
anemia.  We  have  not  had  a  patient  who  lias  been  cured,  but  all  in  all,  in 
about  75  per  cent  of  the  cases  the  benefit  might  be  said  to  be  suflBLcient  to 
justify  the  operation.  In  the  total  number  of  operations  three  patients  in 
our  early  experience  died  from  the  oj)eration ;  the  hemoglobin  was  under  30 
per  cent,  the  red  cells  were  under  a  million.  These  patients  should  have 
been  transfused  before  operation.  Since  practicing  transfusion  in  advance 
of  splenectomy,  when  the  blood  has  been  seriously  deteriorated,  we  have  had 
no  deaths.  There  were  no  operative  deaths  in  the  last  32  cases.  In  many 
cases  after  initial  improvement  by  transfusion  and  splenectomy,  relapse  has 
taken  place,  followed  again  by  improvement  after  transfusion.  We  have 
carried  some  of  these  patients  along  for  months  in  fair  health  by  repeated 
transfusions ;  as  many  as  thirty  have  been  given  to  a  single  patient.  Fol- 
lowing each  transfusion  there  would  be  marked  benefit,  with  gradual  de- 
preciation, until  transfusion  again  became  necessary.  It  has  been  believed 
that  the  introduction  of  new  blood  stimulates  the  hematopoietic  organs,  and 
this  is  probably  the  true  hypothesis  in  patients  whose  bone  marrow  is  not 
too  severely  damaged.  Yet  it  should  be  noted  that  immediately  after  the 
transfusion,  in  certain  cases,  the  anemia  is  relieved,  the  hemoglobin  brought 
up  from  10  to  30  points,  and  the  red  cells  advanced  api^reciably,  only  to  be 
followed  by  a  gradual  decline.  These  are  the  predominately  myelotoxic 
tyi^es.  It  is  an  interesting  conjecture  whether  or  not  the  patient  may  live 
on  the  work  of  transfused  blood  as  well  as  be  stimulated  to  the  formation 
of  new  blood.  A  probable  explanation  is  that  the  life  of  the  red  corpuscles 
is  much  longer  than  we  have  thought,  and  that  the  anemia  returns  in  pro- 
portion as  this  fresh  aid  is  used  up.  The  sigiiificant  blood  changes  in  perni- 
cious anemia  that  differentiate  it  from  secondary  anemias  are  the  changes 
in  the  number  and  type  of  the  red  corpuscles  and  in  the  blast  cells  found 
in  the  blood.  The  blast  cells  are  the  mothers  of  the  erythrocytes,  and  each 
blast  cell  thrown  into  the  blood  represents  a  permanent  loss  of  blood-making 
power.  Therefore,  neither  stimulation  nor  treatment  can  reproduce  that 
which  has  been  lost.  The  difficulty  with  the  whole  subject  of  pernicious 
anemia  concerns  the  fact  that  we  do  not  recognize  the  disease  until  such 
vital  and  permanent  changes  as  are  indicated  in  the  actual  loss  of  these  blast 
cells  have  taken  place.  It  is  even  possible  that  jseruicious  anemia,  in  its 
beginning,  is  not  a  definite  entity,  but  that  it  is  a  terminal  change  of  sev- 
eral conditions  which  we  have  not  recognized  until  they  have  reached  the 


APPENDIX  Z85 

final  stage.  Clinically,  Imwcv.'r,  it  is  a  very  (l(,'fiiiilo  'liscase  wlicn  Lotli  liis- 
toiy  and  blodil  ]iictuic  aic  (l('\c'l(i|icil.  I'cinicious  anoniia  may  be  called  a 
cancer  of  the  n'l]  '•,.ils,  vccouinycii  in  iIk-  hopeless  stage.  "When  the  early 
histories  of  patients  with  ])einicious  anemia  are  studied  the  symptomatology 
seems  fairly  clear;  yet  many  patients  arc  seen  with  anemias  which  are  sus- 
pected to  Le  pernicious  but  which  never  develop  the  true  characteristics  of 
the  disease.  If  pernicious  anemia  is  to  be  cured  it  must  be  done  l^efore 
permanent  damage  to  the  hematopoietic  organs  has  taken  place.  It  is  pos- 
sible that  certain  types  may  be  cured;  yet  so  firmly  fixed  is  our  belief  con- 
cerning the  incurability  of  the  disease  that  should  we  have  patients  cured 
by  splenectomy  we  would  be  inclined  to  lift  them  out  of  the  category  of 
pernicious  anemia  and  to  group  them  with  either  hemolytic  icterus  or  splenic 
anemia. 

To  sum  up,  splenectomy  has  a  field  of  usefulness  in- selected  cases  of 
pernicious  anemia,  especially  in  those  showing  a  marked  hemolysis  by  the 
Schneider  duodenal  test  and  evidence  of  slight  bone  marrow  damage.  The 
operation  of  removal  of  the  spleen  for  pernicious  anemia  is  not,  as  a  rule, 
ditficult.     The  spleen  is  only  of  moderate  size,  and  not  very  adherent. 

Leiilcemia. — If  there  has  been  any  one  condition  believed  to  be  non-sur- 
gical and  incurable,  it  is  splenomyelogenous  leukemia.  The  theory  has  been 
that  95  per  cent  at  least  of  such  patients  operated  on  would  die  as  a  result 
of  the  operation,  and  that  the  5  per  cent  who  lived  would  not  be  benefited. 
Yet  we  have  long  known  therapeutic  agents  (benzol,  x-ray,  etc.)  which  would 
reduce  the  size  of  the  spleen  and  would  also  improve  the  condition  of  the 
blood;  and  as  the  size  of  the  spleen  became  reduced  such  improvement  might 
be  expected.  With  the  use  of  radium,  which  could  be  readily  applied  over 
the  area  of  the  spleen,  a  vast  change  came  about  in  the  therapeusis  of 
splenomyelogenous  leukemia.  I  do  not  know  of  any  clinical  experience  that 
is  more  striking  than  the  result  which  follows  the  application  of  radium 
over  a  huge  leukemic  spleen.  Many  times  the  spleen  shrinks  so  greatly  as 
to  disappear  below  the  left  costal  margin,  the  white  blood  corpuscles  drop 
from  hundreds  of  thousands  to  under  10,000.  I  have  seen  a  leukopenia  pro- 
duced, the  white  cells  dropping  from  600,000  to  3,700  in  five  weeks.  Ac- 
companying this  extraordinary  leduction  m  the  size  of  the  spleen  and  reduc- 
tion in  the  number  of  white  cells  an  equally  extraordinary  improvement  in 
the  anemia  takes  place,  and  the  patient  is  marvelously  benefited.  As  the 
spleen  gradually  increases  again  in  size  the  white  cells  increase,  the  red  cells 
decrease,  and  the  patient  loses  ground.  It  is  well  to  eliminate  all  of  our 
presumptions  concerning  this  disease  and  pause  for  a  moment  in  perspective. 
Reduce  the  size  of  the  leukemic  spleen,  and  synchronously  the  white  cells  go 
down,  the  red  cells  come  up,  and  the  patient  improves.  As  the  spleen  en- 
larges, the  whites  come  up,  the  reds  come  down,  and  the  patient  goes  down. 
Have  we  in  this,  as  iu  so  many  other  instances,  allowed  tradition  to  hamper 
progress  ? 

My  fii'st  experience  in  splenectomy  for  myelogenous  leukemia  was  with 
a  patient  who  came  to  the  clinic  with  a  greatly  enlarged  spleen,  a  white 
count  of  between  200,000  and  300,000,  and  who  gave  a  history  of  having 


286  TROPICAL    SURGERY   AISTD    DISEASES 

had  the  disease  for  two  years.  There  had  been  very  great  improvement 
under  x-ray  therapy;  at  one  time  the  white  cells  were  reduced  by  it  to  a 
point  under  50,000,  but,  as  regularly  happens,  the  x-ray  had  finally  lost 
its  effect,  and  her  condition  when  examined  was  worse  than  it  had  been 
at  any  former  time.  The  patient  herself  was  greatly  impressed  with  the 
definite  comrection  between  the  size  of  the  spleen  and  her  condition,  and  was 
anxious  to  have  it  removed.  I  removed  the  organ,  and  the  patient  made  an 
excellent  surgical  recovery.  Within  ten  days  the  white  cell  count  had 
dropped  to  less  than  50,000  and  the  patient  is  greatly  improved  now,  more 
than  one  year  following  the  splenectomy. 

Based  on  this  experience,  wt  have  in  a  number  of  instances  reduced  the 
size  of  the  spleen  with  radium  until  the  blood  count  approximated  the  nor- 
mal, and  then  removed  the  spleen.  We  have  found  it  inadvisable  to  force 
an  extreme  reduction  of  the  leucocytes  before  splenectomy.  If  the  general 
condition  of  the  patient  is  good,  a  leucocyte  count  of  30,000  or  less  is  satis- 
factory. All  the  patients,  save  two,  have  been  markedly  relieved.  In  the 
19  cases  there  were  no  operative  deaths.  That  these  patients  are  cured  I 
cannot  believe,  but  the  experience  has  been  interesting  and  suggestive. 

Here  again  we  find  ourselves  in  difficulties  not  dissimilar  to  those  in  con- 
nection with  the  etiology  and  clinical  course  of  pernicious  anemia.  One  pa- 
tient in  our  earlier  experience,  I  remember  well,  had  been  treated  for  leu- 
kemia during  a  period  of  five  mouths  in  a  large  and  well-known  hospital, 
and  in  another  for  three  months.  We  diagnosed  the  condition  as  splenic 
anemia.  The  spleen  was  removed,  the  patient  promptly  recovered,  and  has 
remained  well  now  for  more  than  five  years.  It  is  possible  that  we  recog- 
nize leukemia  as  a  disease  only  after  it  has  reached  the  ho^jeless  stage,  a 
terminal  condition  of  a  much  more  common  though  unrecognized  malady. 
It  is  questionable  whether  all  the  cases  of  splenomyelogenous  leukemia  ad- 
vance to  the  point  where  they  are  recognized  as  leukemia.  These  are  inter- 
esting problems  which  can  not  now  be  answered.  Leukemia  may  be  called  a 
cancer  of  the  white  blood,  recognized  in  the  hopeless  stage.  The  leukemic 
spleen  is  not  adherent,  as  a  rule,  and  after  reduction  in  size  by  radium  is 
readily  removed. 

Hemolytic  Icterus. — We  have  performed  splenectomy  19  times  for  hemo- 
lytic icterus.  The  results  have  been  astonishingly  good.  I  do  not  know  of 
an  operation  giving  more  gratifying  results.  The  jaundice  which  the  patient 
has  had  for  perhaps  years  will  be  perceptibly  less  in  forty-eight  hours,  and 
within  four  days  will  have  ciuite  disappeared.  Sixty  per  cent  of  these 
patients  have  complicating  gallstones,  apparently  due  to  the  greatly  thick- 
ened bile,  the  result  of  pigments  derived  from  the  disintegrated  erythrocytes. 
There  are  two  types  of  hemolytic  icterus,  the  familial  or  congenital  type  of 
Minkowski  and  the  acquired  type  of  Hayem  and  Widal.  In  the  familial 
type  several  members  of  the  same  family  may  be  affected,  and  possibly 
it  may  be  found  through  several  generations.  As  a  rule,  it  is  less  serious 
than  the  acquired  variety.  Although  never  robust,  many  times  those  affected 
with  familial  hemolytic  icterus  will  live  out  a  normal  life  expectancy.     The 


APPENDIX  287 

acquired  type  is  imicli  more  serious,  and  ends,  as  a  rule,  in  death  from  some 
intercurrent  malady  after  years  of  chronic  semi-invalidism. 

The  outstanding  features  of  hemolytic  icterus  are  the  enlarged  spleen, 
more  or  less  enlarged  liver,  and  chronic  recurring  jaundice,  without  gross 
oljstiTiction  in  the  bile  ducts.  Biie  is  always  to  be  fouTid  in  the  stool. 
Inasmuch  as  a  high  percentage  of  these  patients  have  complicating  gall- 
stones, they  may  have  an  increase  of  jaundice  due  to  a  secondary  infection 
from  gallstones,  varying  the  syndrome  and  introducing  diagnostic  difficulties. 
These  patients  all  show  marked  anemia,  and  usually  crises  more  or  less 
serious  develop  in  which  there  is  pain  over  the  region  of  the  liver  and  spleen, 
with  malaise,  some  increase  of  temperature,  and  an  increase  of  jaundice. 
Chauffard  and  Widal  have  pointed  out  the  diagnostic  phenomena  of  increased 
fragility  of  the  erythrocyte,  which  is  practically  constant.  Splenectomy,  as 
a  rule,  is  not  difficult  in  these  cases,  for  although  the  spleen  may  be  quite 
large  it  is  seldom  adherent  to  a  marked  degree.  There  was  but  one  opera- 
tive death  in  our  series.  This  patient  was  operated  on  during  a  crisis,  and 
death  probably  would  not  have  occurred  had  the  operation  been  performed 
in  the  interval  between  crises. 

Biliary  Cirrhosis. — Hemolytic  jaundice  is  often  confused  with  eertaia 
tA-pes  of  non-infective  biliary  cirrhosis,  and  especially  with  the  so-called 
Hanoi's  cirrhosis.  We  have  removed  the  spleen  four  times  for  biliary  cir- 
rhosis, which  could  not  be  properly  classified  as  hemolytic  jaundice.  All  the 
patients  were  above  .30  years  of  age.  Were  it  not  for  the  age,  the  cases 
could  be  called  Hanot's  cirrhosis.  The  results  in  three  were  very  satisfac- 
tory. The  jaundice  disappeared  to  a  large  extent,  and  the  patients  were 
able  to  return  to  work ;  but  in  all  the  liver  remained  large.  The  operation 
of  splenectomy  for  biliary  cirrhosis  is  somewhat  troublesome  and  difficult, 
more  so  than  in  hemolytic  icterus.  In  our  cases  the  spleen  was  large  and 
there  were  many  adhesions.  In  two  the  liver  was  sufficiently  large  to  inter- 
fere mechanically  with  the  operation. 

Splenic  Anemia. — Osier  was  one  of  the  first  to  describe  splenic  anemia, 
and  his  classical  contributions,  coming  as  they  did  at  an  early  time,  created 
a  great  and  lasting  interest  in  the  condition.  Splenic  anemia  is  at  least 
a  clinical  entity,  but  has  been  confused  with  many  varieties  of  spleno- 
megalias,  syphilitic,  septic,  malarial,  hemolytic,  jaundice,  pernicious  anemia, 
etc.  Little  by  little  an  irreducible  minimum  is  being  reached  and  a  definite 
type  established.  The  patients  having  large  spleens  develop  a  progressive 
anemia  and  cirrhosis  of  the  liver  as  a  terminal  condition  to  which  Banti  's 
name  has  been  given. 

The  course  of  splenic  anemia  is  chronic.  There  may  be  intervals  of  years 
in  which  the  patieat  enjoys  a  fair  degree  of  health,  but  eventually  it  leads 
to  a  fatal  issue,  the  debilitated  patients  succumbing  to  intercurrent  disease. 

Hemorrhages  from  the  stomach  are  of  frequent  occurrence  in  splenic 
anemia  and  sometimes  hemorrhage  is  the  first  symptom  that  may  be  noted. 
The  hemorrhages  are  probably  gastrotoxic  in  origin  and  while,  as  a  rule, 
fatal  hemorrhage  does  not  result,  frequent,  recurring  hemorrhages  cause 
great  debility.    The  gastric  hemorrhage  of  splenic  anemia  is  a  symptom  well 


288  TROPICAL  SUEGERY  AND  DISEASES 

worthy  of  attention.  It  is  not  different  from  that  which  occurs  in  connec- 
tion with  hepatic  cirrhosis  and  it  is  altogether  probable  that  many  of  the 
unexplained  hemorrhages  from  the  stomach  in  which  no  local  lesion  of  the 
gastric  mucosa  is  to  be  found,  are  a  result  of  the  toxic  condition  wliieh  pre- 
cedes, accompanies,  or  is  caused  by  splenic  anemia  and  cirrhosis  of  the  liver. 
Balfour,  iii  a  paper  on  the  causes  of  gastric  hemorrhage,  calls  special  atten- 
tion to  the  relationship  of  the  spleen  and  liver  to  the  bleeding.  In  gastric 
hemorrhage  we  must  think  of  the  spleen  and  the  liver  as  causative  factors 
just  as  in  the  differentiation  of  the  causes  of  jaundice  the  spleen  must  be 
thought  of  as  well  as  the  liver.  Warthin  and  others  have  found  that  many 
cases  of  splenic  anemia  show  thrombosis  of  the  splenic  vein  after  death 
and  they  believe  that  the  thrombosis  is  the  cause  of  the  splenic  condition. 
In  one  of  our  patients  who  died  the  cause  of  death  was  found  to  be  due  to 
long-standing  splenic  and  portal  thrombosis.  The  final  catastrophe  was 
brought  about  by  thrombosis  of  the  superior  mesenteric  vein.  It  may  be 
contended  that  splenomegaly  associated  with  splenic,  portal,  or  mesenteric 
thrombosis  (one  or  all)  would  be  better  grouped  with  infectious  spleno- 
megaly (probably  streptococcal)  rather  than  with  true  splenic  anemia. 

The  pseudoleukemia  of  infants  described  by  von  Jaksch  is  closely  as- 
sociated, if  not  identical  with  splenic  anemia,  but  because  of  the  hema- 
topoietic variability  of  infancy  is  often  accompanied  by  a  high  white  cell 
count.  Such  cases  are  usually  to  be  relieved  by  dietetic  management,  but 
the  spleen  has  been  removed  with  prompt  and  striking  improvement.  Bal- 
four splenectomized  a  two  and  a  half  year  old  child  presenting  the  com- 
plete picture  of  splenic  anemia. 

Splenic  anemia  is  cured  by  splenectomy  in  a  high  percentage  of  cases 
and  it  should  be  performed  before  portal  cirrhosis  or  thrombosis  of  the 
splenic  vein  occurs.  The  spleen  is  usually  large  and,  as  a  rule,  extremely 
adherent  and  the  operation  is  more  ditficult  and  dangerous  than  in  any  of 
the  various  other  diseases  for  which  splenectomy  is  indicated.  In  43 
splenectomies  for  splenic  anemia  we  have  lost  4  patients. 

Clinically,  patients  with  enlargements  of  the  spleen  are  to  be  seen  in 
whom  the  enlargement  is  apparently  not  producing  symptoms,  but  these 
cases  should  be  looked  on  as  incipient  splenic  anemia.  Such  causeless  spleno- 
megalias  as  I  have  had  opportunity  to  observe  have  eventually  led  to  marked 
secondary  anemia,  although  perhaps  for  years  showing  little  effect  on  the 
patient's  health.  I  have  seen  no  good  and  much  harm  come  from  chronic 
splenomegalia,  and  other  things  l^eing  equal,  such  spleens  should  be  removed 
on  general  principles. 

Portal  Cirrhosis. — The  portal .  cirrhosis  of  the  liver  which  so  frequently 
accompanies  the  later  stages  of  splenic  anemia  have  led  us  to  remove  the 
spleen  in  5  cases  of  primary  portal  cirrhosis  in  which  there  was  enlarge- 
ment of  the  spleen.  The  results  on  the  whole  have  been  gratifying,  al- 
though one  patient  died  following  the  operation.  The  remaining  four  are 
in  satisfactory  condition.  For  those  portal  cirrhoses  with  enlarged  spleen 
which  occur  especially  in  young  adults  without  alcoholic  history,  splenectomy 
would  appear  to  be  indicated.    As  a  matter  of  fact  in  cases  of  this  descrip- 


APPENDIX  289 

tion  Jo  we  not  classify  as  priiiiarv  jjnital  ciriliosis  those  in  wliicli  tiie  liver 
L'oudition  is  discovered  first?  If  the  splenic  enlargement  is  first  oliserved 
we  call  it  splenic  anemia  with  portal  cirrhosis. 

The  technique  of  splenectomy  I  will  not  dwell  on.  For  those  who  are 
interested,  I  would  refer  to  the  article  by  Balfour,  "The  Technique  of 
Splenectomy. ' ' 

BIBLIOGRAPHY 

^Balfour,  D.  C. :     Splenectomy  for  Repeated  Gastrointestinal  HemorrliaKes,  Ann.   Siir?., 

1917,  Ixv,  89-94. 
The  Technique  of   Splenectomy,    Surg.,   Gynec.   and   Oljst.,    1916,   xxiii,   1-6. 

=Chauffard,  A.:  Pathogenic  de  i'ictere  congenital  de  I'adulte,  Sem.  med.,  1907,  xxvii. 
25-29;  Les  icteres  hemolyliques,  ibid.,  1908,  .xxviii,  49-52;  Cholelithiase  pigmentaire 
dans  un  cas  d'ictere  congenital  hemolytique;  analyse  chemique  des  calculs,  I'.ull. 
et  mem.  Soc.  med.  d.  hop.  de  Paris,   1912,  xx.xiv,  80. 

^'Cushny,  A.  R. :     The  Secretion  of  Urine,  Lond.,  X.  Y.,  Longmans,   1917,  241   p. 

■'Eccles,  R.  G. :  The  Tonsils  and  the  Struggle  for  Existence,  Med.  Rec,  1915,  Ixxxviii, 
47-56. 

•'Elliott,  C.  A.,  and  Kanavel,  A.  B. :  Splenectomy  for  Hemolytic  Icterus,  Surg.,  Gynec. 
and  Obst.,   1915,  xxi,  21-37. 

"Giffin,  IT.  Z.:  Splenectomy  for  Splenic  Anemia  in  Childhood  and  for  the  Splenic 
Anemia  of  Infancy,  Ann.   Surg.,   1915,  Ixii,  679-687. 

The  Treatment  by  Splenectomy  of  Splenomegaly  with  Anemia  Associated  with  Syph- 
ilis, Am.  Jour.  Med.  Sc,   1916,  clii,  5-16. 

A  Report  on  the  Treatment  of  Pernicious  Anem^ia  bv   Transfusion  and   Splenectomy, 

Jour.  Am.  Med.   Assn.,   1917,  Ixviii,  429-432. 
Hemolytic  Jaundice:     A  Review  of  Seventeen   Cases,   Surg.,   Gynec.   and   Obst.,   1917, 

XXV,   152-161. 
Observations    on    the    Treatment    of   Myelocytic    Leukemia    by    Radium,    Boston    !Med. 

and  Surg.  Jour.,  1917   (in  press). 
'Hanot,    v.:      Etude    sur    une    forme    de    cirrhose    hypertrophique    du    foie     (cirrhose 

hypertrophique  avec  ictere  chronique),   Paris,    1875,    155    p. 
^Hayem,  G.:     Variete  particuliere  d'ictere  infeciieux  chronique  splenomegalique,  Presse 

med.,  1898,  i,  121-125. 
Nouvelle    contribution   a  I'ictere   infectieux   chronique   splenomegalique,   Bull,   et  mem. 

Soc.  med.  d.  hop.  de  Par.,   1908,  xxv,   122. 
Quoted   by   Krumbhaar,    E.    B.:      A    Classification   and   Analysis   of    Clinical    Types    of 

Splenomegaly  Accompanied  by  Anemia,  Am.  Jour.  Med.   Sc,   1915,  cli,   227-245. 
'■'Jonnesco,  T. :     Splenectomie  pour  hypertrophie  malarique.  Bull,  et  mem.   Soc.   de  chir. 
de   Bucarest,    1901-1902,   iv,   58. 
^"Keith,  A.:     A  New  Theory  of  the  Causation  of  Enterostasis,  Lancet,  1915,  ii,  371-375. 
"Krumbhaar,    E.    B.,    Alusser,    J.    H.,    Jr.,    and    Peet,    M.    M. :      Changes    in    the    Blood 
Following  Diversion  of  the  Splenic  Blood  from  the  Liver,  a.  Control   Study  of  the 
Effects  of  Splenectomy,  Jour.  Exper.  Med.,   1916,  xxiii,  87-95. 
^-Mall,    F.:      A    Study    of   Intestinal    Contraction,    Johns    Hopkins    Hosp.    Repts.,    1896, 

i,  37-75. 
^^Minkowski:     L^eber  einem  hereditarischen,  unter  dem  Bilde  eines  chronischen  Icterus 
mit   Urobilinurie,    Splenomegalie,    und   Nierensiderosis   verlaufende   Affection,    \'er- 
handl.  d.  deut.  Cong.  f.  inn.  Med.,   1900,  xviii,  316. 
"Osier,  W.:     On  Splenic  Anemia,  Am.  Jour.   Med.   Sc,  1900,  cxix,  54-73. 
^"Powers,   C.  A. :     Non-parasitic  Cysts  of  the  Spleen,  Ann.   Surg.,   1906,  xliii,  48-60. 
i^Rosenow,  E.   C. :     Elective  Localization  of  Streptococci,  Jour.  Am.  Med.  Assn.,   1915, 
Ixv,   1687-1691. 
Elective  Localization  of  Bacteria  in  Diseases  of  the  Nervous  System,  Jour.  Am.   !Med. 
Assn.,   1916,  Ixvii,   662-665. 
'■Rous,   Peyton,  and  Robertson,   O.  IT.:     The   Normal   Fate  of  Ervthrocvtes,  Jour.   Ex- 
pen   Med.,   1917,  xxv,   651-663;   664-673. 
'^Vaughan,  V.  C. :     Infection  and  Immunity,  Jour.  Am.  Med.  Assn.,  1915,  p.   164. 
'"Warthin,   A.    S.:      The   Changes    Produced   in    the    Hemolymph   Glands   of   the    Sheep 
and  Goat  bv   Splenectomy,   Contrib.   Med.   Research   (\aughan),  Ann  Arbor,    1903, 
216-236. 
-"Whipple,  G.  IT.,  and  Ilojiper,  C.   W. :     P.ile  Piement  Metabolism,  Am.   Tour.   T'hvsiol., 

1916,  xl,   332,   348;    349-359;    1917,   xlii,   256^263;   264-279;   544-557. 
-'Widal,    F.,   Abrami,   P.,   and   Brule,    jM. :      Differenciation   de  plusieurs   types  d'icteres 
hemolytiques,    Presse   med.,    1907,    xv,    641-644.      Quoted    by    Elliott   and    Kanavel, 
loc.   cit. 


290  TROPICAL    SURGERY   AXD    DISEASES 

Splenectomy 

Balfour  developed  the  present  splenectomy  teclmic  of 
the  Mayo  Clinic  which  consists  hrietly  of  leaving  tlie 
spleen  in  situ  to  hold  back  the  abdominal  organs  while 
it  is  being  shelled  out  by  the  fingers,  packing  carefully 
behind  until  freed  and  brought  out  of  the  abdomen. 
When  adherent  it  is  found  that  after  ten  or  fifteen 
minutes  the  gauze  packing  will  have  controlled  the 
oozing  completely.  The  stomach  is  then  carefully  freed, 
the  tail  of  the  j^ancreas  avoided,  and  the  vesse]s  become 
readily  manageable  by  clamps. 

The  following  is  reprinted  here  from  an  article  that 
appeared  in  Annals  of  Surgery,  August,  1915: 

Surgical  Considerations  of  Splenectomy  (WiHiam  J.  Mayo). — Splen- 
ectomyr — The  safety  of  spleuectomy  depeuds  on  careful  separation  of 
tlie  attackmeuts  of  tte  spleen  and  its  delivery  with-Out  injury  to  the 
vascular  pedicle.  Therefore  much  depends  on  the  size  and  movability  of 
the  spleen  and  the  amount  and  vascularity  of  its  adhesions  as  well  as 
on  the  thickness  of  the  abdominal  wall. 

Incision. — Bevani  in  1897  described  a  most  satisfactory  incision  for  opera- 
tions on  the  gall  bladder  and  biliary  passages  which,  has  been  modified 
by  various  surgeons.  A  longitudinal  incision  is  made  through  the  upper 
rectus  muscle  extending  obliquely  along  the  costal  margin^  about  an 
inch  and  a  half  from  it  and  up  toward  the  ensiform  cartilage.  The 
longitudinal  part  of  the  incision  may  be  carried  down  to  any  desired 
length  permitting  careful  abdominal  exploration.  In  this  respect  its 
value  in  operations  on  the  biliary  tract  is  very  marked,  as  an  appendix 
may  be  removed  or  any  necessary  operation  may  be  performed  on  the 
pyloric  end  of  the  stomach  or  duodenum.  The  incision  made  on  the 
left  side  is  equally  advantageous  in  gaining  access  to  the  spleen.  In 
working  in  the  biliary  region  the  longitudinal  part  of  the  incision  is 
best  made  in  the  inner  half  of  the  rectus  muscle,  for  splenectomy  it  is 
best  made  in  the  outer  half.  If  the  incision  across  the  rectus  muscle 
is  kept  an  inch  or  more  from  the  costal  margin,  this  little  flap,  when 
caught  with  a  catspaw,  makes  an  excellent  retractor. 

Adhesions. — In  most  cases  in  which  splenectomy  is  necessary,  the  spleen 
is  enlarged  and  adherent  to  the  parietal  peritoneum  and  diaphragm 
especially  over  the  upper  pole.  These  adhesions  differ  greatly  in  their 
vascularity,  being  occasionally  purely  vascular,  composed  of  a  small 
artery  and  one  or  more  varicose  veins.  Since  these  vessels  cannot  be 
seen  and  controlled  until  the  spleen  is  loosened  from  its  bed  and  drawn 


*The  Collected  Papers,   !Mayo   Clinic,   1916. 


APPENDIX 


291 


down,  it  is  usually  best  to  separate  them  with  the  fingers  as  close  to 
the  spleen  as  possible,  trusting  the  control  of  any.  hemorrhage  to  a  large 
gauze  pack  until  the  spleen  can  be  delivered  and  removed   (Fig.  68). 


Fig.  68. — The  Bevan  incision  for  splenectomy,  shown  in  v.pper  figure.  Lower 
figure — method  of  using  gauze  pack  for  temporary  hemostasia  to  control  bleeding  of 
separated  adhesions.      (Courtesy   of   Dr.    William   J.  Mayo.) 


At  times  the  spleen  is  firmly  fixed  in  position  by  adhesions   so  stroug 
they  must   be  di%'ided  by   a   cutting  instrument.     By  making   an   opening 


292  TROPICAL    SURGERY    AND    DISEASES 

in  tlie  adhesions  close  to  tlie  splenic  capsule  and  loosening  the  spleen  as 
far  as  possible  by  a  combination  of  enucleation  and  division,  a  very- 
adherent  spleen  may  safely  be  removed. 

A  subscapular  splenectomy,  in  the  sense  one  speaks  of  a  subscapular 
nephrectomy,  is  not  possible.  The  capsule  of  the  spleen  is  closely  as- 
sociated with  the  splenic  pulp  which  is  lacerated  in  the  attempt  to  re- 
move it  from  within  the  capsule,  causing  great  loss  of  blood.  With  a 
little  care,  however,  the  spleen  can  be  separated  immediately  at  the 
capsule,  leaving  the  attachments  in  a  condition  so  there  will  be  com- 
paratively little  bleeding.  In  this  way  the  spleen  can  be  quickly 
delivered  and  the  pedicle  temporarily  controlled  by  fingers  or  an  elastic 
rubber-covered  pedicle  clamp,^.  The  main  thing  to  be  accomplished  is  to 
leave  the  separated  attachments  in" such  condition  that  a  igauze  tampon 
will  temporarily  larevent  bleeding.  In  two  cases  in  my  earlier  experience 
the  spleen  was  so  firmly  fixed  with  vascular  adhesions,  I  did  not  deem 
it  wise  to  undertake  sijlenectomy. 

Separation  of  the  Splenic  Ligaments. — Much  may  he  learned  eoueoniiug 
the  normal  relations  of  the  spleen  by  operative  work  on  the  cadaver. 
The  most  serious  vascular  attachments  are  the  vasa  brevia  in  the 
gastrosplenic  ligament  which  pass  to  the  stomach.  However,  the  bulk 
of  these  attachments  can  be  delivered  with  the  spleen,  since  the  stomach 
can  be  drawn  from  the  abdomen  to  a  very  considerable  extent  before 
separating  the  gastrosplenic  ligament.  Unfortunately,  in  a  large  ad- 
herent spleen  there  may  be  vascular  connections  in  the  deeper  portion 
of  the  gastrosplenic  ligament  which  pass  inward  and  backward  to  anas- 
tomose with  vessels  along  the  spine  and  the  crux  of  the  diaphragm.  Since 
these  must  be  separated  before  the  spleen  can  be  eviscerated,  early  care- 
ful adjustment  of  an  adequate  gauze  tampon,  for  temporary  control  of 
hemorrhage,  may  be  essential.  The  lienorenal  ligament  has  no  great 
vascularity  and  can  be  readily  divided.  After  the  delivery  of  the  spleen, 
the  remainder  of  the  gastrosplenic  ligament  and  a  leash  of  vessels 
passing  to  the  inferior  border  of  the  spleen  which  connect  it  with  the 
splenic  flexure  of  the  colon  are  tied  in  sections.  This  completes  the 
peritoneal  and  omental  attachments  about  the  hilum,  and,  by  dividing 
a  few  adhesions  here  and  there,  the  spleen  can  be  lifted  up  so  that  the 
vascular  pedicle  lies  completely  exposed  for  at  least  two  inches. 

Pancreas. — The  splenic  pedicle  should  be  sea-iched  for  the  tail  of  the 
pancreas  which,  if  present,  will  lie  in  the  pancreatic  notch  of  the  spleen, 
behind  the  hilum.  It  can  usually  be  readily  separated,  a  few  ligatures 
applied  to  bleeding  points,  and  then  dropped  back  into  the  abdomen. 
In  three  splenectomies,  I2  tied  off  a  portion  of  the  tail  of  the  pancreas 
with  the  splenic  pedicle,  in  one  case  removing  as  much  as  an  inch  and 
a  half,  without  any"  harm  resulting.  The  spleen  was  bleeding  so  freely 
from  lacerations  that  time  could  not  be  spared  for  separation.  In  the 
third  case,  in  whicn  the  splenic  vessels  were  atheromatous  and  would 
not  hold  a  ligature,  I  tied  the  splenic  vessels  together  with  the  body 
of  the  pancreas  about  three  and  one-half  inches  from  its  tip  with  two 


APPEXDIX  293 

ligatures  of  catgut,  three-fourths  of  an  inch  apart.  The  patient  re- 
covered ■ivithout  serious  STmptoms. 

The  pancreas  has  five  independent  sources  of  blood  supply  which 
protect  its  circulation.  The  pancreatic  ducts  have  been  shown  clinically 
and  experimentally  to  have  great  powers  of  regeneration.  Fat  necrosis 
as  the  result  of  escaping  pancreatic  secretion  from  injury  to  the  pan- 
creas in  this  situation,  apparently  is  not  to  be  greatly  feared,  probably 
because  its  secretions  are  not  activated  by  duodenal  secretion. 

Vascular  Fedi-cle. — In  the  average  case,  the  vascular  pedicle  can  lie  so 
thoroughly  cleared  that  it  may  be  easily  ligated  in  sections.  The  artery 
should  be  tied  first,  but  all  vessels  should  be  tied  before  any  portion  of 
the  pedicle  is  cut.  In  spite  of  this  precaution  the  spleen  sometimes  tears 
from  the  pedicle  before  it  can  be  ligated.  This  accident  happened  in 
one  of  my  cases — a  fleshy  patient.  The  spleen  had  a.  short  pedicle  which 
retracted  deeply,  but  I  was  able  to  grasp  the  vessels  in  my  fingers  and 
hold  them  until  forceps  could  be  applied.  In  this  type  of  case  it  is 
better  to  grasp  the  entire  pedicle  with  elastic  rubber-covered  clampss 
which  will  temporarily  compress  without  damage  any  attached  viscus, 
such  as  the  wall  of  the  stomach,  until  the  splenic  vessels  can  safely  be 
controlled.  In  two  instances  I  have  iajured  the  stomach  because  of  its 
close  attachment  to  the  splenic  pedicle,  in  one  case  ligating  a  portion 
of  the  wall  of  the  stomach,  in  the  pedicle.  Fortunately  there  was  no 
escape  of  gastric  contents  and  I  was  able  to  repair  the  damage.  The 
patient  recovered.  In  the  second  case  I  was  less  fortunate.  There 
were  large  varicose  veins  in  the  gastrosplenic  ligament  and.  in  making 
a  thorough  exposure  of  the  pedicle,  one  of  the  veins  in  the  waU  of  the 
stomach  was  torn.  Unfortunately,  tooth-forceps  were  used  to  grasp 
.  the  vessel  and  the  fragile  gastric  waU  was  lacerated.  There  was  an 
escape  of  gastric  contents  into  the  bed  from  which,  the  spleen  had  been 
enucleated  and  the  patient  died  a  few  days  later  from  sepsis. 

When  the  vascular  pedicle  has  been  carefully  exposed  but  is  too 
short  for  accurate  ligation  of  the  vessels,  the  two-forceps  method  will 
be  found  very  satisfactory.  In  this  procedure,  two  forceps  are  placed 
three  fourths  of  an  inch  apart  on  the  pedicle  and  the  spleen  cut  away 
Avithout  regard  to  back  bleeding.  A  catgnit  ligature  is  thrown  around  the 
pedicle,  below  the  proximal  forceps,  which  is  then  loosened  and  the  liga- 
ture tied  in  the  compressed  area,  while  the  distal  pair  of  forceps  steadies 
the  pedicle  and  prevents  retraction.  A  second  ligature  makes  the  pedicle 
secure. 

There  are  undoubtedly  some  eases  in  which  splenectomy  is  indicated 
but  iu  which  the  condition  of  the  patient  or  the  attachments  of  the 
spleen  make  the  operation  inadvisable. 

Two  years  ago  Is  suggested  the  possibility  of  ligating  part  of  the 
vessels,  believing  that 'it  would  have  an  effect  comparable  to  the  liga- 
tion of  the  thyroid  vessels  in  hyperthyroidism.  I  have  not  had  an  op- 
portunity to  carry  out  this  suggestion  and  am  not  at  all  sure  that  it  could 


294  TROPICAL  SUEGERY  AXD  DISEASES 

be  done  "witli  any  degree  of  accuracy  unless  tlie  delivery  of  the  spleen 
"n"ere  accomplislied  and  in  tliat  event  splenectomy  would  be  equally 
easy  and  more  effectual. 

John  Gerster*  has  suggested  ligation  of  the  splenic  artery  at  the 
celiac  axis  as  a  preliminai-y  step  in  splenectomy,  or  in  some  cases  as 
a  method  of  producing  atrophy  of  the  spleen  when  it  would  not  be 
practicable  to  remove  it.  He  has  mentioned  the  ease  with  which  the 
celiac  axis  can  be  reached  through  the  gastrohepatic  omentum.  The 
splenic  artery  certainly  could  be  conveniently  tied  at  the  celiac  axis, 
or  just  where  it  lies  at  the  sui^erior  border  of  the  pancreas. 

Experimental  ligation  of  the  splenic  artery  demonstrates  that  the 
normal  spleen  will  not  become  necrotic,  but  that  it  will  undergo  atrophy. 
The  lilood  supply  from  the  splenic  artery  to  the  pancreas  and  stomach 
which  would  be  cut  off  by  lig^ation  is  not  important  and  would  be  well 
taken  care  of  from  the  numerous  anastomotic  branches  of  other  sources. 

Closure,  of  the  Splenic  Space. — This  procedure  is  exceedingly  important. 
Compression  with  the  large  temporary  tampon  will  enable  the  smal- 
ler vessels  to  become  sealed  in  a  few  minutes,  but  in  the  deeper  re- 
cesses of  the  wound,  there  will  probably  be  vessels  requiring  other 
treatment.  With  catgut  on  a  small  curved  needle,  the  raw  space,  be- 
ginning at  the  tied  splenic  vessels,  is  closed  as  well  as  possible.  The 
margin  of  the  lienorenal  ligament,  on  the  outer  side,  is  sufS.ciently  firm  to 
hold  a  suture,  but  on  the  inner  side  such  bits  of  tissue  must  be  caught 
here  and  there,  as  can  be  done  safely  until  the  bleeding  vessels  are  com- 
pressed. The  last  sutures  come  well  down  on  the  diaphragm  and  had 
best  be  applied  during  cardiac  diastole  and  during  expiration.  In  some 
cases  the  splenic  space  will  be  dry  when  the  tampon  is  removed  and 
suturing  is  not  necessary.  To  be  able  to  leave  the  wound  dry  is  a  great 
satisfaction  and  well  worth  the  little  extra  time  taken  to  accomplish 
it.  One  of  my  patients  died  of  so-called  secondary  shock,  due  to  failure 
to  control  hemorrhage  at  a  deep  point,  and  in  two  of  my  earlier  eases, 
before  I  understood  the  value  of  the  snaking  catgut  suture,  I  was  com- 
pelled to  leave  a  large  tampon  to  control  the  oozing  (Fig.  69"). 

Drainage  is  not  needed  unless  there  has  been  injury  to  some  viscus. 
The  after  care  is  quite  the  same  as  that  following  any  abdominal 
operation. 

Mortality  of  Splenectomy. — The  mortality  of  splenectomy  depends  more 
on  the  type  of  case  accepted  for  operation  than  on  the  technical 
difficulty  of  the  operation  itself.  If  the  patient  is  in  good  general 
condition,  a  small,  movable  spleen  can  be  removed  with  a  death 
rate  so  low  as  to  be  almost  accidental.  If  the  spleen  is  enlarged 
but  has  considerable  latitude  of  motion,  splenectomy  may  be  performed 
with  almost  no  mortality  beyond  the  possible  accidents  of  a  serious 
operation.  But  if  the  spleen  is  enlarged  and  adherent  and  the  patient  is 
suffering  from  a  high  grade  of  anemia  with  myocardial  and  renal 
changes,   marked   by    edema    of    the    lower    extremities,    or    is    suffering 


APPENDIX 


295 


from  ascites,  jaundice,  high  temperature,  etc,  the  mortality  will  neces- 
sarilv  be  hioh.  Even  under  these  conditions,  surprisingly  few  patients 
die    directl/  as    the    result    of    the    operation.      In    14    of    our    patients 


Fig.69.-Closure   of   splenic   space   by    snaking   catgut    suture     to    control    oozing   of 
blood  from   deep-seated   areas.      (Courtesy    of   Dr.   \\  illiam  J.    Ma>o.) 

edema  of  the  lower  extremities  was  marked.  Seventeen  had  ascites 
with  coincident  mvocardial  and  renal  changes,  7  were  jaundiced,  and  o 
were   suffering   from   high   temperature    at    the    time    of    the    operation. 


29G  TROPICAL    SURGERY   A:N'D    DISEASES 

There  were  many  combinations  of  these  conditions,  all  in  connection 
with  high  grades  of  anemia,  yet  there  were  but  5  deaths  in  the  hospital 
from  all  causes,  in  the  58  eases  operated  on.  As  shown  by  the  post- 
mortem, 2  of  the  5  deaths  wore  from  preventable  causes  (hemorrhage 
and  sepsis).  In  conclusion,  I  desire  to  express  my  early  indebtedness 
to  J.  Collins  WarrenS  for  his  splendid  x^aper,  "Suz'gery  of  the  Spleen," 
stiinulating   interest  in  the  subject. 

REFERENCES 

'Bevan,  A.   D. :     A  Xew  Incision  for  the   Surgery  of  the  Bile   Tracts,   Tour.   Am.    Med. 

Assn.,    1S97,   xxviii,    1225-1227. 
-Mayo,   W.  J.:     The   Surgery  of  the  Pancreas,  Ann.   Surg.,   1913,  Iviii,   145-150   . 
^Mayo,   W.  J.:     Surgery  of  the   Spleen,   Surg.,   Gynec.   and   Obst.,   1913,  xvi,  233-339. 
''Gerster,  John:     Personal   communication. 
=Warren,  J.  Collins:     The  Surgery  of  the  Spleen,  Ann.   Surg.,   1901,  xxxiii,   513-543. 


GENERAL  INDEX 


Abscess  of  the  spleen,  36 
Abscess,   tropical,   238 
Actinomycosis,  240 
Adenoids  and  tonsils,  241 
Ainluini,  150,  235 
Alcoholism,  20(3 
Aleppo  boil,  144 
Amebiasis,   37 
Amebic  dermatitis,  149 
Amebic  ulcers,  rectum,  91 
Anakhre,  152 
Anesthetics,  23 
Appendicitis,   213,  229 
Appendicostomy,  213 
Arthritides,    158 


Bacillary  dysentery,  66 
Balautidial  dysentery,  63 
Banti's  disease,  26 
Bess  el  Temeur,  144 
Betel  cliewers'   cancer,  28 
Bilharzia  hematobia.   111 
Biskra  button,  144 
Blastomycosis,  gluteal  region,  91 
Blood  i)ressure,  23 
Bronchomoniliasis,   30 
Broncliomycosis,   30 
Buboes,  154 

C 

Calabar  swellings,  114 

Calculi,  urinarv,  235 

Cancer,  222 

Cancer,  neck  and  mouth,  28 

Carcinoma,  222 

Catastrophe  surgery,  92 

Cerebrospinal   meningitis,   203 

Chiggers,  150 

Children,  infectious  diseases  in,  242 

China,  observations  on,  161 

Chinese  medicine.  165 

Chronic  iilcerations,  130 

Chvloeele,  104 

Chylothorax,  104 

Chvlous  ascites,  104 

Cleft  palate,  25 


Climate,  influence,   193 
Clinical  organizations,  22 
Colon,  diseases  of,  37 
Commonest   suigical   diseases,   193 
Congenital  anomalies  of  head,  25 
Congenital    defects,    238 
Cosmopolitan  diseases,  21 


D 


Delhi  sore,   144 
Dermal  leishmauiosis,   144 
Dermatomycosis,    tropical,    145 
Diabetes,  236 
Diseases  of  the  skin,  245 
Diseases   of  women,   224 
Distomum  Hematobium,  111 
Dracontiasis,  113 
Dracunculus  medinensis,   113 
Drug  habits,  206 
Dysentery,   bacillary,   213 
Dysentery,  entamebic,  37 


E 


Ecliinococcus,    240 
Elephantiasis,   99,   24-1 
Elephantiasis  nervorimi,  1(J2 
Emergency  surgery,  92 
Entamebic  dysentery,   37 
Epidemics   of  fomier  times,  18 
Europeans,  habits,  diseases,  etc.,  195 
Ewundu,   151 


Fibromata,  symmetrical,  180,  181 
Filaria  Loa,   114 
Filaria,  prevalence  of,  95 
Filariasis,  95,  234 
Filariasis,  cysts,  9R 
Fistula  in  ano,  239 

tropical,  90 
Fly  bite,  144 

Foot  diseases  and  lesions,  249 
Frambesia    fvaws),   125 
Fuente,   182  " 
Furunculosis,  248 


297 


298 


GENERAL,    INDEX 


G 

Game,  94 

Gaugosa,   116,   250 

Gastric  symptoms,  230 

Genitouiinarv   diseases,   90 

GeuitoiTiiuary  diseases  iu  men,   227 

Glanders,  240 

Goiter,  27 

Gondou,  152,  235 

Guinea  worm,   113 

Gynceologv  and  diseases  of  women, 

224 
Gynecology  and  obstetrics,   86 


Harelijj,  25 

Head,  diseases  of,  25 

Heat  prostration,   94 

Hematochyluria,    111 

Hemorrhage  from  the  liver,  72 

Hemorrhage  in  typhoid  fever,   68 

Hemorrhoids,  239 

Hepatic  abscess,  69 

Hernia,  33,  237 

Hodgkin's  disease,  26,  236 

Hookworm  belt,  19 


Infantile   paralysis,    237 
Infectious,  cause  of  disease,  IS 

pyogenic,   155 
Insect  borne  diseases,  18,  19 
lutertrige   saceharmomycetica,   147 
Intestinal  parasites,   216 
Intestinal  parasitism,   67 
Intestinal  Avorms,  216 


Japan,  observations  on,  172 
Japan,   surgery  in,   173 
Jelly  fish  poisoning,   93 

K 
Kala-azar,    34,   144,    210 


Laboratory  methods  iu  diagnosis,  23 
Leeches,  94 

Leishmania   donovaui,   144 
Leoutiasis,  153,  232 
Leprosy,  134,  231 
surgery  of,  140 
Liver  abscess,  69,  219 


Liver,  entamebic  abscess,  69 
Ludwig's   angina,   25,   244 
"Lumi-lumi,"  200 
LATuph   varicose   glands,   110 
Lymph  varix,   110 
Lymphatic   cysts,   27 

M 

Madura   foot,    149,    240 
Malaria,    203,    204,    205 
Multiplicity  of  diseases,  23 
Mutilations,  military,  25 
Mycetoma,   149 

N 

JSTative    and    home    diseases,    252 
Native  treatment  of  wounds,  199 
Neck,  diseases  of,  25 
Neurofibromatosis,    102 
Nodules,    juxta-articular,    99 


O 


Obstetrics  and   gynecology,   86 
Obstetrics,   native,    225 
Operating  room   technic,    22 
Operation   for   liver   abscess,    72 
Oriental   sore,   144 
Osteomyelitis,  typhiod,  212 


Paralysis  agitans,   237 
Parasitism,   intestinal,   67 
Parotitis  tyi^hoid,   212 
Pemphigus    contagiosum,    249 
Pliilippines,   medical   surveys,   178 

observations  on,  174 
Plague   of   fiery   serpents,   113 
Plagues    of    Middle   Ages,   18 
"Prickly  heat,"   247 
Pulse,   23 
Pyogenic  infections,  155 


Questionnaire,    answers    to,    183 
races,    physical    conditions,    food 
and  habits,  184 

K 

Recklinghausen's  disease,  25 
Rectum,  ulcers,  amebic,  91 
Resistance    to    surgery,    shock    and 

infection.     Aseptic  results,  190 
Rickets,   25 


GENERAL    INDEX 


299 


s 

.Sand  flea,  151 

(Sarcoma,   222 

.Sarcopsylla   penetrans,    151 

Skin,  diseases  of,  144 

Skin   diseases,   245 

Skin  granulomas,  233 

Snakes  and  snake  bites,  93 

Spirillum   fever,   203 

Spleen,    257    (see    Appendix) 

abscess  of,  36 

diseases  of,  34  (see  Appendix) 
Splenic  anemia,   34    (see  Appendix) 
Sunlight,   cause   of  disease,  17 
Surgical  material,   23 
Surgical   tuberculosis,    208 
Syphilis,  130,  211 

fourth  stage   of,   116 

T 

Tartar  emetic  in  kala-azar,  35 

Temperature,   23 

Tetanus,   155 

Tetanus  neonatorum,  200 

Thorax,  diseases  of,  25 

Tinea   capitis,    147 

cruris,    146 

flava,   147 

imbricata,   147 

nigra,   147 
Tonsils   and    adenoids,   241 
Trichomycosis    flava,    et   nigra,    148 


Tiicliophyton    skin    infections,    247 
Tropical  abscess,  238 
Tro|)ical   dermatomycosis,   145,   245 
'J'ro[)ical  diseases  in  white  races,  17 
Tropical  liver,  40,  219 
Tropical    ulcer,    233 
Tulierculous  nodes,  neck,  26 
Tulierculosis,    surgical,    143,    20S 
Typhoid  complications,  212 


Ulcers,   tropical,   233 
Ulcers,   rectum,  amel^ic,   91 
Urinary  calculi,  235 

V 

A^'alue  of  medical   research,  20 
Varicose  veins,  239 
Volcanic  burns,  92 

W 

Women's  diseases,  222 

Worm  of  Pharaoh,  113 

Wounds,   infections,   treatment,    198 


Yaws,   116,  232 

Castellani  's  treatment  of,  129 


IXDEX  OF  GEOOEAPHICAL  REGIOXS 


A 

ArracA,  36,  111,  150,  152,  205,  209 
Agra,  Ixdia,  186,  190,  193,  196,  198, 

208 
Asia,  34 

B 
Barbados.   137 
Basutolaxd,  135 

BUR2JA,  190,  193.  195,  198,  199,  203, 
206,  208,  210 


Caxal  Zoxe,   144 

Cape  Towx,  S.  A..  141 

Carolixe  Islands,  116 

Ceylox,  30,  31,  91,  128.  188,  193, 

196.  198,  199.  203,  207. 
209 

Ch-VXGSHa,  Chixa,  133 

Chixa.  36,  131,  144,  161,  203,  205, 

209.  210 
Colombo,  Ceylox.  188.  191,  205 
Corfu,  129,  130 

E 
Egypt,  91,  111 

F 
Formosa.    90,    188.    192.    193,    194. 

197,  199.  203,  206,  207,  209 

G 
Guam.  n6.  124.  131.  1S6,  192.  197. 

200,  204,  206,  210 
GuiXEA.  Frex'CH,  98 

H 
Hatyah,  134 
Honduras.   155 

HOXGKOXG.  191.  193,  196,  203,   207 
Hwatyuax,  Axiiatei,  Chixa,  34 


Ix-DLV,  104,  144.  150.  186.  190,  193. 
196,  198.  203,  205,  206,  208 
Ivor;Y  Coast,  154 


Japan,  172 

Johaxxesburg,    Africa,    232,    233, 
234,  235 


K 


Korea,  189,  193,  194,  197,  200,  206, 
207,  209 


Liberia,  98 


L 

M 


MACEDOx^A,  130 

Madagascar,   99 

]!ilALAY  States,  30 

Manila,    195,    212,    234,    235,    242 

245,  249 
Mariaxas,  116 
Marshall  Islaxds,  116 
MOLOELU.  Hattaii.  141 


X 


^.YASALAXT),    99 


Persia.  36 

PiXG  Yix,   191,  193,   198,  199 

Portuguese  East  Africa,  187 


Eaxgoox',  212 


Ba:moa,  131.  186,  192,  194,  199,  203, 

206,  208,  209 
SoocHOTY,  191,  196 
South  Africa,  187,  191.  203,  241 
South  Amepjca,  152 

SOUTHERX   IXTilA,   80 

Styedex",  63 


T 


Tarsus.  116 
ToMA,  98 
Titikestax.  112 


W 


West  Africa,   114,   150,   ISS,    191, 

207,  241 
Wexcuow,  191,  193,  198 

Z 

Zamboaxga.  p.  I.   IS 7-191 


300 


IXDEX  OF  AUTHOES 


Adeluxg,  111 

ailbutt  axd  eollestox,  67 

AXDEEWS,    33 
ASl'LAXD,    210 

Avisox,  188,  255 


Baetjer,  57 

Baxks,  179 

Baebee,  256 

Barlow,  155 

Baury,  256 

Beax,  179 

Blake,  Sir  Henry,  IS 

BOTREAr-KOUSSEL,    154 

BowiiAX",  63 
BRUilPT,  150 
BuxTiXG  AXD  Yates,  26 

C 

CadblTvY,  165 
Carxochax,   103 
Caroxia,  35 

ClEROLL,    19 

Castellaxi,  30,  91,  99,  101,  128,  145 

155 
Castor,  256 
Chalmers,  155 
Chambeklaix',  256 
Charles,  Sir  Havelock,  101,  104 
Clapier,  98 
Cl-\ek,  231 

Clegg,  37,  136,   149,  178 
COCHEAX,  34 

Cottle,  184,  255 
Craig,  37 
Ceeightox,  152 
CUEEEL,  188,  207,  255 

D 

D.^JEOiiNG,  37,  144 

DeLambotte,  107 

BeSilva,  256 

Di  Cheistixa  AXD   Caroxia,   35 

Dig   Chrysostom,   116 

dobbeetix,  106 

Drumjioxd,  105 


EcK,   105 
Eggers,   131 
Elkixs,  112 
Ejiily,  114,   115 
Eaieich,  61 

F 

Faul,  255 
Ferguson,  33 
Feschexko,  113 
Fola\-ell,  188,  255 

G 

Cachet,  36 

Gaeeisox,  116,  124,  178 

Gessxee,  104 

GiFFix,    (see  Appendix) 

Goodhue,  141,  142 

GORGAS,    20 


Hail,  188,  255 

Haxdley,   100,   103,   105,   107 

Haxsex,  136 

Haestox,  256 

Heisee,  140 

Hexschex",  106 

Hiest,   188,  255,  243 

Hollexbeck,  188,  255 


Jeaxselme,   147 
JOHXSOX,  188,  255 

K 

Kaetulis,  91 
Kexg,   149 
Kerr,  116,  123 
Koch,  19 

Koxdeleox,  103,  105 
KuRiEX,  128 

KUZXETZOFF,   103 


Laxdsborougii,  255 
Laxz,  103 


301 


302 


I5TDEX    OF    AUTHORS 


Laetigau,  6S 

L AVER AX,    204 

Lazear,  19 
Leiper,  113 

LEISHilAX-DOXOVAN,     34 

LeXouemaxt,  103 
Lyxx,  90 

M 

Mackie,  35 

Maclaud,  153 

Maxsox,  19,  95,  113,   153 

Matas,  103,  104 

]\'Iaxwell,  90 

Mayo,  34,  105,  257 

McDiLL,   74,   96,   97,   107,   157 

McDiLL  and  Wherry,  157 

Miller,  188,  255 

Mills,   189,   255 

morrisox,  105 

Morrow,  135 

Moses,  134 

Musgrave,  37,  149 


Xarath,  105 
XiCHOLS,    95,    234,    256 
XOETOX,   188,   255 

O 

OcnsxER,  24,  256 

Odell,   116,   124,   186,   255 

Oh.  241 

Oppel,  103 

Osler,  37 


Page,  255 

Phalex,   95,   234,   256 

Philippixe    Jourxal    OF    Sciexce, 

182 
Phillips,  256 
Plummer,   256 
Pi"RViAXCE,  188,  255 


E 


E,EED,  19,  133 
Eeid,  188,  255 


Robertson,  112 
Rogers,  19,  36,  59 
ROSAXOW,  103 

Rose,   19 

rosexbaum,  116 

Ross,  188,  255 

Ross,  Sir  Roxald,  19,  144,  204,  256 

ROSSITER,    254 

RosT,  231 

S 

Sabouralt),    99,    146 
Saxdes,  141,  142 
Schiassi,  105 
Sellarus,  37,  57 
Sexx,  116 
Shakespeare,    19 
Shiga,  67 
Smith,  255 
Sxell,  255 
Stitt,  93 
Stryker,  202,  188 

T 

Talaia,    105 
Turner,   187,    256 


IT 


Urological     Coxgress     of     1912, 

Germax,    112 
UxxA,    99 

V 

VAX  BusKiRK,  188,  255 
Vaughax,  18 
Vedder,  37,  59,  256 

W 

Walker,  19,   37,  64,  65 
Weir,   188,  222,  241,  255 
Wellmax,  111,  150 
Wells,  188,  255 
Wherry,  96,  111 
Wherry  and  McDill,  157 
Wyxter,  105 


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